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College  of  ^jjpgiciartJf  anti  ^urgeong 


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©r,  CbtDin  p.  Cragin 

1859-1918 


A  MANUAL  OF  GYNAECOLOGY 

AND 

PELVIC  SURGERY 
SK  E  EL 


A  Manual  of  Gynaecology 


AND 


Pelvic  Surgery 

FOR 

STUDENTS  AND  PRACTITIONERS 


BY 

•     ROLAND  E.  SKEEL,  A.  M.,  M.  S.,  M.  D. 

Associate   Clinical   Profejssor   of    Gynecology,    Medical    School   of    Western 
Reserve  University;  Visiting  Surgeon  and  Gynecologist  to  St.  Luke's 
Hospital,  Cleveland;  Fellow  of  American  Association 
OF   Obstetricians   and   Gynecologists; 
Fellow    of  American   Col- 
lege OF  Surgeons 


WITH  TWO  HUNDRED  AND 
EIGHTY-NINE  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

1012  WALNUT   STREET 


Copyright,  1916,  by  P.  Blakiston's  Son  &  Co. 


THE    MA.PUE     PRRSH     YORK    PA 


PREFACE 

This  manual  is  intended  to  furnish  a  concise,  practical  work- 
ing knowledge  of  gynaecology  with  especial  emphasis  upon  diag- 
nosis and  treatment. 

Much  time  has  been  devoted  to  the  selection  of  references  in 
the  hope  that  the  book  may  prove  to  be  useful,  not  only  to 
medical  students,  but  to  general  practitioners  and  those  who 
make  gynaecology  the  greater  part  of  their  daily  work. 

The  references  bear  no  relation  to  the  author's  expressed 
opinions,  but  have  been  so  selected  as  to  indicate  the  thought 
of  representative  investigators  and  clinicians  upon  all  the  sub- 
jects dealt  with,  and  a  sufficient  number  has  been  included  to 
enable  the  reader,  by  their  systematic  use,  to  gain  a  compre- 
hensive knowledge  of  every  phase  of  the  subject. 

They  will  also  serve  as  the  author's  acknowledgment  of 
indebtedness  to  those  writers  whose  opinions,  methods,  etc.,  he 
may  have  copied  either  consciously  or  unconsciously. 

The  book  references  are  intended  for  collateral  reading  by 
students  for  whom  journal  articles  and  society  transactions  may 
not  be  available. 

Every  endeavor  has  been  made  to  treat  the  subject  of  gynae- 
cology as  it  really  exists,  viz.,  as  a  highly  specialized  branch 
of  general  surgery  bearing  a  close  relationship  to  obstetrics, 
and  demanding  a  thorough  knowledge  of  general  medicine  for 
a  proper  appreciation  of  its  relative  importance  in  the  medical 
field  with  its  multiplicity  of  specialties. 

The  chapter  on  Anatomy  was  prepared  by  Dr.  A.  J.  Skeel, 
Obstetrician  to  St.  Luke's  Hospital,  Cleveland,  Ohio. 

The  micro-photographs  are  by  Dr.  C.  V.  Keller,  Instructor 
in  Pathology  in  the  University  of  Michigan. 


CONTENTS 

CHAPTER  I 
ANATOMY 

PAGE 

The  Vulva 2 

The  Perineal  Region 5 

The  Pelvic  Diaphragm   .    -.  ■ 11 

The   Vagina 14 

The  Urethra 18 

The  Rectum.    . 18 

The  Pelvic  Basin  and  Contents 20 

The  Uterus 26 

The  Ovary -. 32 

The  Uterine  Tubes 33 

The  Urinary  Bladder 35 

The  Ureters 38 

The  Uterine  Ligaments 39 

The  Broad  Ligaments 39 

The  Pelvic  Fascia 41 


CHAPTER  II 

PHYSIOLOGY 

Menstruation 44 

Definition 44 

Onset 45 

Cessation 46 

Cause  of  Menstruation 46 

Histological  Changes  in  Uterus 47 

Ovulation 49 

Definition 49 

Corpus  Luteum 5^ 

Pregnancy  and  Labor 51 

Fertilization 51 

Definition  of  Pregnancy 51 

'  vii 


Vlll  CONTENTS 

CHAPTER  III 

SYMPTOMATOLOGY  AND  DIAGNOSIS 

Page 

Family  History 54 

Personal  History 55 

Gynaecologic  Pain 56 

LeuGorrhea 59 

Menstrual  Disorders  as  Symptoms 61 

Amenorrhea 62 

Dysmenorrhea 64 

Menorrhagia  and  Metrorrhagia 66 

Examination  and  Objective  Signs 67 

Preparation  for  Examination 69 

Anaesthesia  for  Examination 69 

Position  for  Examination 69 

Instruments  for  Examination 71 

Inspection 71 

Percussion 75 

Auscultation : 77 

Palpation 78 

Digital  Vaginal  Examination 81 

Bi-manual  Vaginal  Examination 82 

Digital  and  Bi-manual  Rectal  Examination 83 

Microscopic  Examinations 84 

Examination  of  the  Urine 86 

Examination  of  the  Bladder 87 

Technique  with  Kelley  Instruments • .  89 

Technique  with  Electrically  Lighted  Instruments 90 

Technique  with  Harris  Segregator 92 

CHAPTER  IV 

DISEASES  AND  INJURIES  OF  THE  VULVA 

Vulvitis 97 

Stenosis  of  the  Vulva      loi 

Pruritus  vulvae      loi 

Kraurosis  Vulvae      103 

Chancre 103 

Chancroid 105 

Condylomata 106 

Bartholinitis 108 

Tumors no 

Urethral  Caruncle 1 1 1 


CONTENTS  IX 

Page 

Vaginismus 112 

Parasites 116 

Injuries 117 


CHAPTER  V 

INJURIES  TO  THE  PERINEUM  AND  PELVIC  DIAPHRAGM 

Types  of  Injury 120 

Etiology 122 

Secondary  Results,     Cystocele,  Rectocele,  Symptoms 122 

Immediate  Repair  of  Perineal  Injuries 126 

Secondary  Repair  of  Perineal  Injuries 132 

Anterior  Colporrhaphy 132 

Incomplete  Laceration 138 

Hegar  Operation 140 

Emmett  Operation      142 

Split  Flap  Operation 147 

Complete  Laceration 152 

Simple  Operation 153 

Split  Flap  Operation 153 

General  Remarks 158 

After-care 160 


CHAPTER  VI 

DISEASES  AND  INJURIES  OF  THE  VAGINA 

Vaginitis 163 

Tumors 166 

Injuries 166 

Vesico-vaginal  and  Recto-vaginal  Fistulae 167 

Operations  for  Vesico-vaginal  Fistula      169 

Operations  for  Recto-vaginal  Fistula 172 


CHAPTER  VII 

DISEASES  AND  INJURIES  OF  THE  CERVIX 

Erosion 175 

Endocervicitis  and  Cervical  Polypi      178 

Laceration  of  the  Cervix l8l 

Hypertrophy  of  the  Cervix 183 

Stenosis  of  the  Cervix 184 


X  CONTENTS 

Page 

Carcinoma  of  the  Cervix 185 

Operations  on  the  Cervix 192 

Dilatation 192 

Repair  of  Cervical  Laceration 193 

Immediate  Repair 193 

Secondary  Repair 194 

Amputation  of  the  Cervix 198 

Schroeder's  Amputation  and  Its  Modifications 198 

Circular  Amputation 202 

Amputation  with  the  Cautery 208 

Curette  and  Cautery 211 

Massive  Cauterization  (Percy) 212 


CHAPTER  VIII 

DISEASES  OF     THE  UTERINE  BODY 

Endometritis 218 

Acute  Endometritis 218 

Chronic  Endometritis 220 

Uterine  Polypi 225 

Sub-involution 226 

Hyper-involution 226 

Chronic  Metritis      226 

Uterine  Fibro-myomata 227 

Malignant  Diseases  of  the  Uterine  Body 241 


CHAPTER  IX 

DISPLACEMENTS  OF  THE  UTERUS 

General  Considerations 248 

Classification  of  Displacements 250 

Mallocations 251 

Descent  or  Prolapsus  Uteri 252 

Malpositions 260 

Anteversion 260 

Anteflexion 262 

Retroversion  and  Retroflexion 263 

Inversion  of  the  Uterus 274 

Injuries  to  the  Uterus 278 

Perforation  of  the  Uterus 278 

Rupture  of  the  Uterus 280 


CONTENTS  XI 

CHAPTER  X 

OPERATIONS  UPON  THE  UTERUS  AND  ITS  LIGAMENTS 

Page 

Curettage .  283 

Vaginal  Fixation 285 

Vaginal  Hysterectomy 288 

Inguinal  Shortening  of  the  Round  Ligaments 297 

Intra-abdominal  Shortening  of  the  Round  Ligaments 300 

Ventrosuspension  of  the  Uterus 306 

Ventrofixation 3^7 

Myomectomy 309 

Vaginal  Myomectomy 309 

Abdominal  Myomectomy 312 

Hysterectomy 314 

Supravaginal  Hysterectomy 314 

Operative  Modifications  for  Unusual  Conditions 323 

Panhysterectomy 33 1 

Panhysterectomy  for  Carcinoma  of  the  Cervix 336 

Combined  Vaginal  and  Abdominal  Operation  for  Carcinoma  of  the 

Cervix 348 

CHAPTER  XI 

DISEASES  OF  THE  UTERINE  TUBES 

Acute  Salpingitis 353 

Symptoms  and  Clinical  History 357 

Differential  Diagnosis 360 

Prognosis 362 

Treatment 363 

Tuberculosis  of  the  Tubes. 365 

Salpingectomy 367 

CHAPTER  XII 

EXTRA-UTERINE  PREGNANCY 

Etiology 3B1 

Life  History  of  Extra-uterine  Ovum 382 

Symptomatology  and  Diagnosis 388 

Preceding  Rupture 389 

Symptoms  at  Time  of  Rupture 392 

After  Rupture,  the  Ovum  Dead 394 

After  Rupture,  the  Ovum  Living 395 

Prognosis 397 


Xll  CONTENTS 

Page 
Treatment 398 

Treatment  at  Time  of  Rupture 398 

Treatment  after  Rupture 401 

Vaginal  Section  in  the  Treatment  of  Extra-uterine  Pregnancy  ....   403 

CHAPTER  XIII 

DISEASES  OF  THE  OVARIES 

Acute  Oophoritis 406 

Prolapse  of  the  Ovary 413 

Tumors  of  the  Ovary 415 

Pathology 415 

Clinical  Course  and  Prognosis  of  Ovarian  Tumors 421 

Accidents 421 

Symptoms  and  Diagnosis  of  Ovarian  Tumors 424 

Operations  upon  the  Ovaries 428 

Resection  of  the  Ovary 428 

Ovariotomy 429 

Parovarian  Cystectomy 437 

CHAPTER  XIV 

PELVIC  PERITONITIS,  PELVIC  CELLULITIS 

Peritonitis 440 

Etiology 441 

Gross  Pathology 442 

Prognosis 446 

Treatment 447 

Chronic  Pelvic  Peritonitis 44^ 

Acute  Pelvic  Cellulitis 449 

Symptoms,  Diagnosis,  and  Clinical  Course 449 

Treatment 45^ 

Chronic  Pelvic  Cellulitis 45  ^ 

Posterior  Vaginal  Section 452 

CHAPTER  XV 

CONGENITAL  ANOMALIES 

Hermaphroditism 459 

Anomalies  of  the  Hymen 462 

Anomalies  of  the  Vagina 4^3 

Anomalies  of  the  Uterus  and  Tubes 464 

Anomalies  of  the  Ovaries 4^6 

Operations  for  Genital  Atresia 4^7 


CONTENTS  XIU 

CHAPTER  XVI 

STERILITY,    GONORRHEA,    THE    TREATMENT    OF    MENSTRUAL 

DISORDERS 

Page 

Sterility 471 

Etiology 471 

The  Treatment  of  Sterility 474 

Gonorrhea 475 

The  Treatment  of  Menstrual  Disorders 479 

Amenorrhea      480 

Dysmenorrhea 481 

Menorrhagia  and  Metrorrhagia 483 

CHAPTER  XVII 

GYNECOLOGIC  THERAPEUTICS 

Rest 488 

Exercise 491 

Suggestion 492 

Vaccines,  Antitoxins,  and  Specific  Chemical  Therapy 493 

Local  Therapeutics 496 

Vaginal  Douches 501 

Radiotherapy 503 

CHAPTER  XVIII 

DISEASES  CLOSELY  RELATED  TO  OR  ASSOCIATED  WITH  GYNE- 
COLOGIC LESIONS 

Urethritis 507 

Acute  Cystitis 508 

Chronic  Cystitis 512 

Hemorrhoids 515 

Appendicitis 526 

Acute  Appendicitis. 526 

Chronic  Appendicitis 539 

Appendectomy 543 

Visceral  Ptosis 555 

CHAPTER  XIX 

GYNECOLOGIC  SURGERY 

Pre-operative  Treatment 561 

Asepsis  and  Antisepsis 563 

Anaesthesia 572 


XIV  CONTENTS 

Page 

Instruments 581 

Incisions 583 

Haemostasis 586 

Suture  and  Ligature  material 587 

Tying  Ligatures  and  Sutures 590 

Closing  Incisions 591 ' 

Drainage 593 

Dressings 597 

After-care 600 


CHAPTER  XX 

POST-OPERATIVE  COMPLICATIONS  AND  SEQUELJE 

Shock 611 

Post-operative  Hemorrhage 613 

Post-operative  Infection 616 

Post-operative  Intestinal  Obstruction 620 

Intestinal  Resection,  End-to-end  Anastomosis 624 

Fecal  Fistula 633 

Intestinal  Resection,  Lateral  Anastomosis 636 

Foreign  Bodies  in  the  Abdomen 640 

Acute  Gastric  Dilatation 643 

Suppression  of  Urine 644 

Ligation  of  Ureters 645 

Post  operative  Bronchitis  and  Pneumonia 646 

Pulmonary  Embolism _ 648 

Phlebitis 649 

Post-operative  Adhesions 650 

Post-operative  Psychoses 651 

Index 659 


MANUAL  OF  GYN/ECOLOGY 

CHAPTER  I 
ANATOMY 

A  definite  knowledge  of  anatomy  is  necessary  for  the  proper 
understanding  not  only  of  gynaecologic  surgery,  but  also  of 
symptomatology  and  the  extension  of  disease  processes.  The 
reason  why  pain  in  one  locahty  may  be  due  to  inflammatory 
disease  or  mahgnant  infiltration  in  another  is  readily  explained 
by  the  peripheral  nerve  distribution  from  a  common  nerve 
trunk,  or  a  close  association  between  the  nerve  centers  govern- 
ing both  regions.  The  route  of  extension  from  a  distal  focus 
of  infection  of  trivial  character,  to  a  proximal  location  whose 
invasion  jeopardizes  hfe  is  appreciated  through  a  knowledge  of 
the  continuity  of  surfaces,  lymphatic  distribution,  or  venous 
return  from  the  original  atrium  of  infection. 

In  the  present  chapter  an  attempt  is  made  to  review  the 
sahent  points  in  the  anatomy  of  the  parts  concerned  in  gynae- 
cology, and  to  make  the  review  sufficiently  full  and  accurate  to 
serve  as  a  ready  reference  upon  any  obscure  points  of  practical 
importance.  Since  originaHty  in  descriptive  anatomy  is  ob- 
viously impossible,  no  apology  is  intended  in  stating,  that  that 
which  follows  is  largely  but  a  condensation  from  accepted 
authorities.  The  Enghsh  translation  of  the  B.N. A.  is  used 
except  where  the  Latin  forms  have  been  Anghcized  by  common 
usage  or  where  the  use  of  Latin  terms  makes  the  diction 
smoother.  The  older  terminology  is  placed  in  parenthesis 
whenever  the  newer  seems  in  danger  of  being  misunderstood 
by  reason  of  its  wide  deviation  from  the  earHer  anatomical 
terms. 


2  ANATOMY 

THE  EXTERNAL  GENITALIA 

In  the  description  of  the  external  genital  parts  the  subject 
is  presumed  to  be  in  the  lithotomy  position  in  which  there  are 
visible  the  vulva,  the  perineum,  and  the  anus. 


Fig.  I. — External  genitals  of  female.     (After  Morn's.) 
THE  VULVA 

The  vulva,  or  pudendum,  is  a  term  used  to  designate  that 
part  of  the  female  sexual  apparatus  external  to  the  vaginal 


THE   EXTERNAL   GENITALIA  3 

orifice.  It  comprises  the  mons  pubis,  the  labia  majora,  the 
posterior  commissure,  the  labia  minora,  the  chtoris,  the  vesti- 
bule of  the  vagina,  and  the  external  orifice  of  the  urethra.  In 
nulliparae  the  hymen  is  present,  either  ruptured  or  intact, 
and  after  labor  its  remnants  are  found  as  the  hymenal 
caruncles. 

The  mons  pubis  consists  of  a  thick  pad  of  fat  and  connective 
tissue  overlying  the  os  pubis.  It  is  covered  with  skin  from 
which  springs  a  thick  growth  of  coarse  hair  arranged  in  the 
form  of  a  triangle  with  its  base  upward.  Extending  posteriorly 
from  the  mons  pubis,  one  at  either  side  of  the  pudendal  slit, 
are  two  large  folds  of  integument  from  7  to  8  cm.  in  length 
known  as  the  labia  majora,  whose  outer  surfaces  are  pigmented 
and  covered  with  a  growth  of  hair  continuous  with  that  over 
the  mons  pubis.  On  their  inner  surfaces,  where  they  are  in 
contact,  their  skin  is  more  delicate  and  they  are  supplied  with 
sebaceous  glands. 

The  posterior  ends  of  the  labia  majora  unite  about  3  cm. 
anterior  to  the  anus,  their  point  of  junction  being  known  as  the 
posterior  commisure  or  fourchette. 

Each  labium  majus  contains  a  dense  layer  of  connective  and 
adipose  tissue  in  which  is  a  rich  plexus  of  veins.  In  its  an- 
terior end  is  found  the  external  termination  of  the  uterine 
round  ligament  which  here  frays  out  and  blends  with  the  con- 
nective tissue  of  the  labium.  The  fissure  between  the  labia 
majora  is  known  as  the  pudendal  slit,  and  in  the  hthotomy 
position  this  appears  as  a  vertical  cleft  while  in  the  erect  position 
it  is  horizontal. 

The  labia  minora  consist  of  delicate  folds  of  integument  con- 
taining connective  tissue  and  but  little  fat.  They  lie  internal 
to  the  labia  majora  and  may  be  considered  as  arising  at  the 
junction  of  the  posterior  one-third  with  the  anterior  two-thirds 
of  the  latter  structures.  From  here  they  extend  anteriorly 
to  the  chtoris  where  they  divide  into  two  portions.  The  an- 
terior or  larger  division  passes  over  the  chtoris  to  form  its  pre- 


4  ■  ANATOMY 

puce  while  the  posterior  or  smaller  unite  to  form  its  fraenum. 
The  labia  minora  are  pink  in  color,  have  few  or  no  hairs  upon 
tTieir  surface,  and  are  richly  supplied  with  nerve  filaments. 
They  contain  sebaceous  glands  opening  both  upon  their  internal 
and  external  surfaces. 

The  clitoris  is  the  homologue  of  the  male  penis  and  like  the 
latter  is  erectile.  It  is  about  3  cm.  in  length  and  situated  im- 
mediately beneath  the  junction  of  the  anterior  division  of  the 
labia  minora.  The  clitoris  consists  of  a  glans-or  head,  a  corpus 
or  body,  and  two  crura  or  roots.  The  glans  covers  the  distal 
extremity  but  it  is  not  penetrated  by  the  urethra  as  it  is  in  the 
corresponding  male  organ. 

The  body  is  made  up  of  two  corpora  cavernosa  as  in  the  male 
penis,  the  corpus  spongiosum  of  the  latter  being  represented  by 
the  vestibular  bulbs  which  may  be  considered  as  two  halves  of 
a  split  corpus  spongiosum  which  connect  anteriorly  with  the 
erectile  tissue  of  the  clitoris. 

The  vestibular  bulbs  are  pyriform  in  shape,  their  larger  ex- 
tremities extending  posteriorly  nearly  to  the  posterior  com- 
missure, thus  partially  surrounding  the  vaginal  orifice,  while 
the  corpora  cavernosa  are  attached  to  the  pubic  rami  and  form 
the  crura  of  the  clitoris. 

The  vaginal  vestibule  is  the  area  lying  between  the  labia 
minora  superior  to  the  vaginal  orifice.  In  the  mid-line  of  the 
vestibule  posteriorly  is  the  external  urethral  orifice  which  lies 
from  I  to  il^  cm.  below  the  pubic  arch.  This  orifice  is  from 
4  to  5  mm.  in  diameter  and  on  its  vaginal  margin  has  a  slight 
prominence  marking  its  position.  The  para-urethral  ducts 
(Skene's  glands)  are  found,  one  at  either  side,  opening  either 
just  within  or  just  without  the  meatus.  In  addition  there  are 
a  number  of  shallow  foUicles  opening  upon  the  mucous  surface 
of  the  vestibule  in  the  same  localit}'. 

The  larger  vestibular  glands  (Bartholin's  glands)  open  one  on 
either  side  of  the  vaginal  orifice  a  little  posterior  to  a  line  drawn 


THE   PERINEAL   REGION  5 

transversely  across  its  middle,   the  orifice  of  the  duct  lying 
between  the  hymen  and  labia  minora. 

The  hymen  is  a  fold  of  mucous  membrane  which  partially 
occludes  the  vaginal  orifice,  and  it  contains  connective  tissue 
and  blood-vessels  between  its  layers.  It  is  usually  crescentic 
in  form  with  the  concavity  anteriorly,  but  it  may  be  annular, 
cribriform,  or  wholly  imperforate,  in  the  latter  event  entirely 
occluding  the  vaginal  orifice.  This  membrane  is  so  delicate 
that  ordinarily  it  is  ruptured  at  the  first  intercourse  or  even 
by  vaginal  examination,  but  occasionally  it  persists  until  after 
the  first  labor. 

THE  PERINEAL  REGION 

The  perineal  region  is  a  lozenge-shaped  area  whose  anterior 
angle  is  at  the  sub-pubic  ligament,  its  posterior  at  the  tip  of  the 
coccyx.  The  lateral  angles  are  at  the  ischial  tuberosities.  It 
will  be  noticed  that  this  area  is  perforated  by  three  orifices, 
the  external  urethral,  the  vaginal,  and  the  anal,  and  it  is  not 
to  be  confounded  with  the  small  ''perineal  body"  which  hes 
between  the  anus  and  the  vaginal  outlet. 

A  line  connecting  the  ischial  tuberosities  lies  about  2  cm. 
anterior  to  the  anus  and  divides  the  perineal  surface  into  an- 
terior and  posterior  triangles.  In  the  mid-hne  of  the  posterior 
triangle  is  seen  the  external  anal  orifice.  In  the  anterior  tri- 
angle are  found  the  urethral  and  vaginal  orifices. 

The  blood  supply  of  the  vulva  and  perineum  is  derived  from 
the  external  and  internal  pudendals  (pudics).  The  internal 
pudendals  pass  deeply  along  the  ischial  and  pubic  rami  giving 
off  numerous  superficial  branches  in  their  course.  Branches 
from  the  internal  pudendal  supply  the  corpora  cavernosa,  the 
bulbi  vestibuli,  and  the  labia.  The  veins  correspond  to  the 
arteries.  The  inferior  hemorrhoidal  vessels  supply  the  skin 
of  the  posterior  anal  triangle.  The  lymphatics  of  the  two  sides 
communicate  anterior  and  posterior  to  the  vaginal  orifice  and 
terminate  in  both  the  femoral  and  inguinal  lymphatic  glands, 


6  ANATOMY 

hence  the  appearance  of  inguinal  and  femoral  lymphadenitis 
in  connection  with  infections  about  the  vulva. 

The  superficial  nerves  are  derived  from  the  inferior  pudendal, 
the  inferior  hemorrhoidal,  and  the  superficial  perineal. 

Midway  between  the  anus  and  the  vaginal  orifice  is  the  central 


Fig.  2. — Diagrammatic    representation    of    the    female    perineal    structures. 

{After  Morris.) 


point  of  the  perineum  at  which  the  various  fascial  layers  of  the 
region  unite,  and  two  of  the  paired,  the  bulbo-cavernosi  and 
transversus  perinei,  and  one  of  the  single  superficial  perineal 
muscles,  the  external  sphincter  ani,  are  attached  at  this  point. 
The  bulbo-cavernosus  arises  from  this  point  in  the  perineum 
and  passes  anteriorly  as  a  muscular  band  about  2  cm.  in  width, 


THE   PERINEAL   REGION  7 

lying  lateral  to  the  vaginal  orifice  and  external  to  the  greater 
vestibular  gland  and  vestibular  bulb.  Anterior  to  these  the 
muscle  separates  into  three  bundles  for  insertion:  (a)  as  an  ex- 
ternal set  which  attaches  to  the  pubic  rami  and  the  fibrous 
tissue  of  the  corpus  cavernosum;  (b)  a  median  set,  the  constrictor 
radices  clitorides,  crossing  and  constricting  the  crus  of  the 
clitoris  and  terminating  in  its  suspensory  ligament;  and  (c) 
an  internal  bundle  which  is  inserted  into  the  anterior  vaginal 
wall  between  the  clitoris  and  external  urethral  orifice. 

The  nerve  supply  is  furnished  by  the  pudendal  through  its 
superficial  perineal  branches. 

The  transversus  perinei  superficialis  is  a  bundle  of  fibers 
taking  origin  from  the  inferior  (ascending)  ramus  of  the  ischium 
and  the  base  of  the  uro-genital  trigone.  It  passes  transversely 
to  its  insertion  at  the  central  point  of  the  perineum  where  some 
of  its  fibers  interlace  with  those  of  the  external  sphincter  ani. 
It  is  supplied  by  the  superficial  perineal  branch  of  the  pudendal 
nerve. 

The  sphincter  ani  externus  is  an  ellipse-shaped  muscle  which 
encircles  the  anal  canal.  It  is  composed  of  superficial  and 
deep  portions.  The  sphincter  ani  superficialis  takes  its  origin 
from  the  dorsal  aspect  of  the  last  piece  of  the  coccyx  passing 
anteriorly  to  the  anus,  where  it  divides  into  two  lateral  halves 
which  encircle  the  lowermost  extremity  of  the  anal  canal  and 
unite  at  the  central  point  of  the  perineum.  The  deep  portion 
of  the  external  sphincter  is  more  nearly  circular,  is  not  attached 
to  the  coccyx,  and  blends  above  with  the  pubo-rectal  fibers  of 
the  levator  ani.  Most  of  the  fibers  terminate  in  the  central 
point  of  the  perineum,  but  some  of  them  decussate  anterior  to 
the  anus  and  are  attached  to  the  inferior  ramus  of  the  ischium 
of  the  opposite  side.  Superficially  the  external  sphincter  is 
in  relation  with  the  skin,  mesially  with  the  wall  of  the  anal 
canal.  The  anus  may  be  forcibly  occluded  by  voluntary  con- 
tractions of  the  muscle  and  its  tonic  contraction  assists  in 
keeping  the  anus  constantly  closed.     Its  nerve  supply  is  de- 


8  ANATOMY 

rived  from  the  pudendal  and  muscular  branch  of  the  fourth 
sacral. 

The  ischio-cavernosus  (erector  clitoridis)  muscle  surrounds 
the  crus  of  the  clitoris.  It  extends  along  the  ischio-pubic  ramus 
from  the  ischial  tuberosity  to  the  cKtoris,  its  fibers  arising  from 
the  tuberosity  of  the  ischium  and  the  ischio-pubic  ramus  and 
inserting  by  a  tedious  expansion  into  the  surface  of  the  crus. 

The  sphincter  urethra  memhranacece  (compressor  urethrae)  con- 
sists of  two  portions,  a  sphincter  proper  of  the  urethra,  and  a 
supporting  portion  which  blends  with  the  layers  of  the  uro- 
genital trigone. 

The  sphincter  portion  arises  from  the  fibrous  tissue  above 
the  urethra  and  behind  the  symphyseal  surface  of  the  pubis, 
and  passing  around  the  urethra  on  either  side  is  inserted  into 
the  fascia  between  the  urethra  and  the  anterior  vaginal  wall. 

The  supporting  portion  of  the  muscle  consists  of  fibers  running 
transversely  in  a  thin  layer  between  the  fascial  planes  of  the 
uro-genital  trigone.  They  arise  largely  from  the  inferior  rami 
of  the  pubes  and  are  inserted  in  the  mid-line  (a)  above  the 
urethra,  {b)  beneath  the  urethra,  and  {c)  into  the  vaginal  wall. 
Many  unstriped  fibers  are  found  in  the  substance  of  this  muscle. 

The  transversus  perinei  profundus  lies  posterior  to  the 
sphincter  of  the  membranous  urethra  but  in  the  same  plane  be- 
tween the  fascial  layers  of  the  uro-genital  trigone.  Its  fibers 
arise  from  the  ischio-pubic  rami  and  pass  mediad  to  be  inserted 
in  the  mid-Hne  both  anterior  and  posterior  to  the  vagina. 

FASCIA 

The  fascia  of  the  perineal  region  consists  of  four  layers,  the 
two  more  superficial  being  made  up  of  two  layers  of  the  super- 
ficial perineal  fascia.  The  superficial  layer  of  the  superficial 
fascia  is  of  no  importance  since  it  is  continuous  with  the  general 
superficial  fatty  fascia  of  the  body. 

The  deep  layer  of  the  superficial  fascia  is  of  more  importance. 
Externally  it  is  attached  to  the  margin  of  the  ischio-pubic  rami 


THE    PERINEAL    REGION  9 

and  tuberosity  of  the  ischium.  Anteriorly  it  is  continuous  with 
the  fascial  covering  of  the  chtoris.  As  it  passes  posteriorly,  it 
is  pierced  by  the  vaginal  orifice,  and  posterior  to  the  vaginal 
orifice  it  covers  the  transversus  perinei  superficialis  and  then 
turns  upward  behind  it  to  unite  with  the  deep  and  superficial 
layer  of  the  uro-genital  diaphragm  (triangular  hgament),  to- 
gether with  which  it  forms  the  posterior  hmit  of  the  deep  and 
superficial  interspace.  Between  this  fascia  and  the  superficial 
layer  of  the  uro-genital  diaphragm  are  found  the  superficial 
transversus  perinei,  the  ischio-cavernosa,  and  the  bulbo-caver- 
nosa  muscles,  the  crura  cHtoridis,  the  vestibular  bulbs,  the 
greater  vestibular  glands,  the  arteries,  veins  and  lymphatics 
of  the  chtoris,  the  superficial  perineal  vessels  and  nerves,  and  the 
perineal  branches  of  the  posterior  femoral  cutaneous  (small 
sciatic)  nerves.  The  space  containing  these  structures  is 
known  as  the  superficial  or  inferior  perineal  space. 

The  inferior  fascia  of  the  uro-genital  diaphragm  (superficial 
layer  of  the  triangular  hgament)  forms  the  deep  boundary  of 
the  superficial  interspace  just  described.  It  consists  of  trans- 
versely arranged  fibers  attached  to  the  ischio-pubic  rami  on 
either  side,  runs  directly  across  the  pubic  arch,  and  extends  as 
far  posteriorly  as  the  perineal  shelf  where  it  unites  with  the  deep 
layer  of  superficial  fascia  and  superior  fascia  of  the  uro-genital 
diaphragm.  In  the  female  this  layer  is  pierced  by  the  vaginal 
orifice  and  it  attaches  to  the  vaginal  walls  near  the  introitus. 
Anteriorly  it  assists  the  superior  layer  and  sphincter  of  the 
urethra  in  supporting  and  fixing  the  urethral  and  vaginal  walls. 
Between  this  layer  of  fascia  and  the  superior  layer  of  the  uro- 
genital diaphragm  is  the  so-caUed  superior  perineal  interspace 
in  which  are  found  the  sphincter  of  the  membranous  urethra  and 
the  deep  transverse  perineal  muscles,  the  internal  pudendal  ar- 
teries and  veins,  pudendal  nerves  and  lymphatics,  and  the  dorsal 
nerves  of  the  chtoris.  The  perineal  vessels  and  nerves  pierce 
this  fascia  near  its   base  to  enter  the  superficial   inter-space. 

The  pudendal  vessels  and  nerves  are  the  terminal  portions 


lO 


ANATOMY 


of  those  structures  and  lie  in  a  groove  dose  to  the  ischio-pubic 
rami,  their  ultimate  termination  being  the  dorsal  vessels  and 
nerves  of  the  clitoris.  The  arteries  to  the  vestibular  bulbs  pass 
transversely  mediad  from  their  origin  in  the  internal  pudendals, 
pierce  the  inferior  layer  of  the  fascia  of  the  uro-genital  dia- 


FiG.  3. — Section  of  the  female  pelvis.     "  Perineal  body  is  not 
wedge-shaped."     {After  Spalleholz.) 


phragm,  and  enter  the  bulbs.  The  vessels  to  the  clitoris  pass 
through  a  small  space  immediately  beneath  the  sub-pubic 
arcuate  ligaments. 

The  superior  fascia  of  the  uro-genital  diaphragm  (deep  layer 
of  triangular  ligament)  might  be  described  as  a  continuation 


THE  PELVIC  DIAPHEAGM  II 

of  the  obturator  fascia  interrupted  by  its  attachment  to  the 
ischio-pubic  rami.  Like  the  inferior  fascia  it  spreads  across 
the  pubic  arch  and  is  pierced  by  the  vaginal  passage  and  urethra. 
It  forms  the  superior  boundary  of  the  superior  perineal  inter- 
space and  extends  posteriorly  to  unite  with  the  other  fascial 
layers  of  this  region  at  the  perineal  ledge  or  shelf  where  it  helps 
to  form  the  posterior  boundary  of  these  interspaces. 

The  perineal  body  of  the  female  is  formed  by  a  heavy  develop- 
ment of  the  perineal  ledge  which  is  produced  through  the  fusion 
of  the  three  layers  of  fascia  above  described,  together  with 
the  superficial  transverse  perineal  muscles,  the  posterior  fibers 
of  the  deep,  and  a  very  few  fibers  of  the  levator  ani.  The  per- 
ineal body  is  broad  at  its  base,  which  is  the  skin  surface,  and 
extends  from  the  posterior  commissure  to  the  anterior  border 
of  the  anus.  Superiorly  it  ends  in  a  wedge  about  3  cm.  from 
the  surface,  the  wedge  terminating  in  a  thin  fascial  layer  which 
separates  the  posterior  vaginal  wall  from  the  anterior  wall  of 
the  rectum.  Just  above  the  level  of  the  internal  anal  sphincter 
the  perineal  body  in  the  living  subject  presents  a  forward  curve 
of  its  posterior  surface  which  probably  is  due  to  the  tonic 
contraction  of  the  levator  ani  muscles,  the  result  of  which  is  to 
destroy  the  usual  anatomical  conception  of  the  perineal  body 
as  a  wedge  with  its  base  downward. 

THE  PELVIC  DIAPHRAGM  (Pelvic  Floor) 

The  pelvic  diaphragm  closes  in  the  lower  end  of  the  abdomino- 
pelvic  cavity,  its  principal  component  parts  being  the  coccygeus 
and  levator  ani  muscles  with  the  fascia  covering  them. 

The  coccygeus  is  in  direct  relation  with  the  anterior  border 
of  the  pyriformis.  It  arises  from  the  spine  of  the  ischium, 
the  border  of  the  sacro-sciatic  notch,  and  the  sacro-spinous 
Hgaments,  and  spreads  out  to  become  attached  to  the  sides  of 
the  lower  sacral  and  upper  coccygeal  vertebrae.  The  distended 
rectum  is  in  contact  with  its  visceral  surface. 

The  levator  ani  forms    the  greater  portion  of  the  muscular 


12 


ANATOMY 


pelvic  diaphragm  and  really  is  composed  of  two  separate 
muscles,  an  anterior,  the  pubo-coccygeus,  and  a  posterior, 
the  ilio-coccygeus.  Each  of  these  arises  from  the  pelvic  wall 
and  both  are  covered  on  their  superior  or  visceral  surfaces  by 
the  endo-pelvic  fascia.  The  posterior  portion,  or  iho-coccygeus 
muscle,  takes  its  origin  from  the  tendinous  arch  of  the  levator 
ani  muscle  (white  line  of  the  pelvis)  which  extends  from  the 


^ 

^ 

^^ 

Bl 

/ 

\  m^         l^k 

^H^HF^^E^  i^WsiA 

^Hr 

/"W 

M^ 

m 

r 

Fig.  4. — Pelvic  diaphragm  seen  from  below  and  behind.     {Ajlcr  Morris.) 

posterior  surface  of  the  os  pubis  to  the  spine  of  the  ischium. 
The  muscle  fibers  extend  in  a  thin  sheet  posteriorly  and  mediae! , 
the  muscles  of  the  right  and  left  sides  meeting  in  the  mid-line 
between  the  tip  of  the  coccyx  and  the  anus,  the  most  posterior 
fibers  being  inserted  into  the  coccyx.  This  bundle  of  fibers 
is  slight  and  of  less  importance  than  the  anterior. 

The  pubo-coccygeus  takes  its  origin  from  the  posterior  surface 


THE    PELVIC   DIAPHRAGM 


13 


of  the  OS  pubis  and  from  the  anterior  portion  of  the  tendinous 
arch  of  the  levator  ani.  Its  fibers  pass  inferiorly,  posteriorly, 
and  mediad,  lateral  to  the  vagina  and  rectum,  joining  their 
fellows  of  the  opposite  side  in  the  median  line  posterior  to 
the  anus.  A  few  of  the  fibers  are  attached  to  the  rectal  wall, 
and  a  small  slip  joins  the  median  raphe  anterior  to  the  anus 


Fig.  5. — Pelvic  diaphragm  seen  from  above  after  removal  of  rectum  and 
separation  of  pubic  bones.     (After  Morris.)  -~ 

uniting  with  the  external  sphincter  ani  and  central  tendon  of 
the  perineum.  The  few  fibers  which  join  the  central  tendon 
of  the  perineum  correspond  to  the  slip  which  surrounds  the 
prostate  of  the  male. 

The  anterior  borders  of  the  pubo-coccygei  leave  a  narrow 
triangular  interval  between  them,  with  its  apex  posteriorly. 
The  anal  canal  lies  at  the  apex  of  this  space  just  anterior  to 


14  ANATOMY 

the  junction  of  the  two  muscles,  while  the  vagina  and  urethra 
pass  through  the  wider  anterior  portion  of  the  interval.  The 
pubo-coccygei  therefore  lie  lateral  and  posterior  to  the  vagina 
near  its  outlet  and  are  subject  to  over-distension  and  laceration 
during  labor.  When  the  pubo-coccygei  contract,  the  upper 
ends  remain  so  fixed  by  their  attachments  that  the  shortening 
of  the  muscles  diminishes  the  concavity  of  the  sling  which 
they  form  by  their  junction  behind  the  anus.  This  action 
raises  the  diaphragm  upon  which  the  pelvic  viscera  rest.  It 
also  lifts  the  anus  upward  during  defecation,  and  at  all  times 
supports  the  anal  canal  and  vaginal  outlet  thus  keeping  them 
in  their  normal  location  in  relation  to  the  pubic  arch. 

The  levator  ani  is  supphed  by  the  third  or  fourth  sacral  and 
sometimes  by  both. 

The  coccygeus  muscle  is  supplied  by  the  fourth  and  fifth 
sacrals  which  form  a  plexus  on  its  anterior  surface. 

A  careful  consideration  of  the  muscles  and  fascia  of  this  region 
explains  why  a  median  laceration  of  the  pelvic  diaphragm  is 
unimportant  so  long  as  it  does  not  include  the  external  sphincter 
ani,  the  muscles  involved  being  so  insignificant  that  no  deleteri- 
ous result  follows,  while  a  tear  in  the  lateral  sulci  deprives  the 
anal  and  vaginal  outlets  of  their  normal  support  and  allows 
the  latter  to  gape  widely.  In  making  a  vaginal  examination 
upon  a  patient  with  an  injured  pelvic  diaphragm,  the  sling 
formed  by  the  superficial  margin  of  the  levator  muscles  is 
readily  felt,  while  it  is  conspicuous  by  its  absence  when  these 
muscles  have  been  injured.  The  severe  hemorrhage  which 
follows  a  deep  injury  to  the  lateral  and  superior  margins  of 
the  vaginal  orifice  is  explained  by  the  location  of  the  vestibular 
bulbs,  and  the  occasional  occlusion  of  the  ducts  of  the  vestibular 
glands  by  a  poorly  performed  perineorraphy  is  easily  understood. 

THE  VAGINA 

^^_The  vagina  is  a  tubular  canal  which  extends  from  the  introitus 
upward  and  backward  to  terminate  by  encircling  the  neck  of 


THE  VAGINA 


15 


the  uterus  about  midway  between  its  external  and  internal 
orifices.     Its  anterior  wall  is  from  7  to  8  cm.  and  its  posterior 


8  to  10  cm.  in  length. 


The  vaginal  introitus  is  rather  firmly  fixed  and  is  relatively 
inelastic  because  of  the  attachments  of  the  perineal  and  uro- 
genital layers  of  fascia,  but  above  this  the  walls  are  elastic  and 
very  distensible.  "  Normally  the  anterior  and  posterior  walls 


Fig.  6. — Female  organs  of  generation  (modified  from  Sappey)  vagina  opened 
from  behind.     Posterior  view.     {After  Morris.) 


of  the  vagina  are  in  contact  with  each  other  while  the  lateral 
walls  are  some  distance  apart,  a  section  at  right  angles  to  the 
long  axis  of  the  vagina  showing  the  vaginal  canal  as  a  trans- 
verse slit,  each  end  of  the  sht  having  an  anterior  and  posterior 
diverticulum  so  that  the  section  in  its  entirety  represents  the 
letter  H.  The  long  axis  of  the  vagina  forms  an  angle  of  thirty 
degrees  with  the  long  axis  of  the  body. 

At  its  upper  end  where  the  vagina  encircles  the  cervix,  the 


1 6  ANATOMY 

greater  length  of  the  posterior  vaginal  wall  is  explained  by  its 
attachment  3  cm.  higher  than  is  the  anterior  wall. 

Anteriorly  in  the  mid-line  is  a  marked  longitudinal  column, 
the  rugarum  anterior,  while  the  posterior  wall  presents  a  similar 
but  less  distinctly  marked  structure. 

From  both  these  columns  transverse  folds,  the  rugae  vaginales, 
pass  laterally  toward  the  sides  of  the  vagina.  These  folds  and 
columns  are  permanently  smoothed  out  during  labor  so  that 
they  are  less  distinctly  marked  after  this  event.  The  upper 
end  of  the  vagina  is  divided  into  anterior,  posterior,  and 
lateral  fornices  by  the  projecting  cervix. 

RELATIONS    OF   THE  VAGINA 

Anteriorly  the  lower  portion  of  the  vaginal  wall  is  in  relation 
with  the  urethra,  its  middle  and  upper  portions  with  the  base 
of  the  bladder  and  ureters.  Posteriorly  the  lower  portion  is 
separated  from  the  anal  canal  by  the  perineal  body,  the  mid- 
portion  is  in  relation  with  the  rectum,  and  the  upper  portion 
for  I  to  2  cm.  is  in  relation  with  the  recto-uterine  excavation. 
The  lateral  vaginal  walls  are  in  contact  with  the  vaginal  bulbs 
inferiorly,  their  middle  one-third  lies  just  mediad  to  the  levator 
muscles,  and  at  the  upper  third  of  each  is  the  ureter  running 
obliquely  outward  across  the  lateral  vaginal  wall  of  the  corre- 
sponding side.  The  vaginal  arteries  and  veins  also  lie  in  contact 
with  the  lateral  vaginal  walls.  Superior  to  the  lateral  vaginal 
fornices  are  found  the  broad  ligament  bases  which  contain  the 
uterine  vessels  and  ureters  and  the  connective  tissue  of  the 
parametrium. 

The  coats  of  the  vagina  are  mucous,  muscular,  and  fibrous. 
The  mucous  coat  is  lined  by  stratified  squamous  epithelium, 
is  devoid  of  glands,  and  more  nearly  corresponds  to  a  cutaneous 
than  a  mucous  surface.  The  muscular  coat  is  thin  and  is  com- 
posed of  unstriped  fibers  continuous  with  those  of  the  uterus. 
The  outer  coat  is  made  up  of  elastic  fibrous  tissue  derived  from 
the  endo-pelvic  fascia. 


THE  VAGINA 


17 


The  blood  supply  is  from  three  sources.     The  upper  end  is 
supplied  by  vaginal  branches  of  the  uterines,  the  mid-portion 


Fig.  7. — Horizontal  section  of  vagina  and  adjacent  structures. 
{After  Henle  and  Morris,) 

from  the  inferior  vesicals,  and  the  lower  from  the  middle  hemor- 
rhoidal and  pudendal.     The  veins  form  a  plexus  external  to 


1 8  ANATOMY 

the  vaginal  walls  and  terminate  in  the  hypogastrics.  The 
nerve  supply  comes  from  the  hypogastric  plexus,  the  fourth 
sacral,  and  the  pudendal. 

The  female  urethra  corresponds  to  the  proximal  portion  of 
the  male  urethra  and  is  about  4  cm.  in  length,  extending  from 
the  apex  of  the  vesical  trigone  to  the  external  urethral  orifice. 
It  has  an  average  diameter  of  7  mm.,  its  widest  portion  being 
about  the  middle,  its  narrowest  at  the  external  orifice. 

Its  mucous  coat  is  thrown  into  longitudinal  folds  giving  it  a 
corrugated  appearance.  The  mucous  coat  possesses  many 
small  tubular  glands  especially  in  its  upper  portion.  External 
to  the  mucous  coat  is  a  muscular  coat  composed  of  a  circular 
and  longitudinal  layer.  At  the  vesical  orifice  the  circular  fibers 
are  strongly  developed  into  a  bundle  which  constitutes  the 
vesical  sphincter.  The  lower  .portion  of  the  urethra  is  firmly 
fixed  by  its  attachments  to  the  anterior  wall  of  the  vagina  and 
the  fascial  layers  of  the  uro-genital  trigone.  The  mid-portion 
is  less  strongly  attached  and  so  sags  sHghtly  posteriorly. 

THE   RECTUM 

The  rectum  is  from  10  to  12  cm.  in  length  and  begins  at 
the  distal  termination  of  the  pelvic  colon  at  the  level  of  the 
middle  of  the  third  sacral  vertebra.  It  is  distinguished  by  the 
absence  of  a  mesentery.  From  its  origin  the  proximal  portion 
extends  downward  and  terminates  in  the  anal  portion  where 
the  intestine  pierces  the  pelvic  diaphragm.  Superiorly  the 
rectum  lies  on  the  anterior  surface  of  the  sacrum  and  coccyx. 
Inferior  to  the  coccyx  it  hes  on  the  muscular  diaphragm. 

At  the  proximal  end  of  the  rectum  the  peritoneal  coats 
separate  from  the  posterior  rectal  wall  until  this  is  uncovered; 
then  the  lateral  walls  become  bared  leaving  only  the  anterior 
surface  covered.  About  23^  cm.  above  the  point  where  the 
intestine  pierces  the  pelvic  diaphragm  the  peritoneum  folds 
forward  from  its  anterior  wall  to  the  posterior  wall  of  the  upper 
end   of   the  vagina,  thence  upward   on  the  posterior  surface 


THE  RECTUM 


19 


of  the  uterus.  Below  the  level  at  which  this  fold  leaves  the 
rectum  the  bowel  has  no  peritoneum.  The  rectum  presents 
three  dilatations  or  saccules  of  which  the  largest  is  the  ampulla 
just  above  the  levator  ani.  The  folds  of  mucous  membrane 
and  circular  muscle  which  separate  the  saccules  have  given  rise 
to  much  discussion  as  the  valves  of  the  rectum. 

The  anal  part  of  the  rectum  is  from  23^^  to  4  cm.  in  length  and 
extends  from  the  levator  ani  muscles  to  the  anal  orifice.  It 
is  compressed  by  four  muscles,  the  external  sphincter  ani  lying 
inferiorly.  In  immediate  proximity  to  this  is  the  internal 
sphincter  which  consists  of  a  considerable  thickening  of  the 
circular  muscle  fibers  of  the  intestine  itself  and  is  an  intrinsic 
portion  of  its  wall.  The  two  levator  ani  muscles  compress 
the  bowel  laterally  just  proximal  to  the  level  of  the  internal 
sphincter.  The  direction  of  the  rectum  as  it  approaches  the 
pelvic  diaphragm  is  well  anteriorly,  but  it  turns  sharply  back- 
ward as  it  passes  through  this,  and  the  anal  portion  extends 
downward  and  backward  to  its  termination  at  the  muco- 
cutaneous margin  which  marks  the  anal  orifice. 

In  the  upper  portion  of  the  anal  canal  are  found  numerous 
vertical  folds  of  mucous  membrane  which  contain  an  artery 
and  a  vein.  These  are  the  rectal  columns  of  Morgagni,  and  the 
veins  in  the  lower  portion  of  these  columns  and  the  area  just 
inferior  to  them  constitute  a  sub-mucous  venous  plexus  which 
is  the  pile-bearing  area. 

The  lower  ends  of  the  rectal  columns  are  connected  by  trans- 
verse folds  of  mucous  membrane  called  the  anal  valves,  at  the 
level  of  which  is  the  muco-cutaneous  junction  known  as 
Hilton's  white  hne. 

The  rectal  blood  supply  is  mainly  from  the  superior  hemor- 
rhoidal artery  which  divides  into  lateral  branches,  one  on  each 
side  of  the  rectum.  The  inferior  portion  of  the  rectum  is 
supplied  by  the  middle  and  inferior  hemorrhoidal  arteries  also. 

The  inferior  and  middle  hemorrhoidal  veins  anastomose 
freely  with  the  superior  hemorrhoidal,  the  latter  terminating  in 


20  ANATOMY 

the  inferior  mesenteric  which  is  part  of  the  portal  system,  hence 
the  connection  between  hepatic  congestion  and  hemorrhoids. 

The  cerebro-spinal  nerves  of  the  rectum  are  derived  from  the 
second,  third,  and  fourth  sacral;  the  sympathetics  from  the 
inferior  mesenteric  and  pelvic  plexuses.  The  anal  skin  is 
supplied  by  the  inferior  hemorrhoidal  branch  of  the  pudendal 
nerve. 

The  skin  and  muco-cutaneous  junction  of  the  anus  drain  into 
the  inner  set  of  inguinal  lymph  glands  as  does  the  perineum. 

The  rectum  is  drained  by  a  system  of  lymphatics  which  end 
in  the  ano-rectal  nodules  along  the  walls  of  the  rectum  following 
the  course  of  the  superior  hemorrhoidal  vessels,  and  in  the 
lateral  sacral  nodules  on  the  anterior  surface  of  the  sacrum,  all 
eventually  terminating  in  the  common  iliac  lymph  glands. 

THE  PELVIC  BASIN  AND  CONTENTS 

On  viewing  the  superior  opening  of  the  small  pelvis  from 
above,  there  are  found  the  following  structures  at  its  circum- 
ference. Beginning  at  the  mid-Hne  anteriorly  the  fundus  of 
the  bladder  extends  to  a  point  at  or  just  below  the  crest  of 
the  pubes.  Lateral  to  this  and  just  internal  to  the  pubic 
tubercle  (spine)  is  the  round  ligament  of  the  uterus  running 
over  the  pubic  pecten  or  crest  to  terminate  in  the  labium  majus. 
The  base  of  the  subcutaneous  inguinal  ring  (external  inguinal 
ring)  is  noted  at  this  point.  External  to  the  pubic  tubercle  and 
extending  from  the  inguinal  Hgament  (Poupart's  Hgament) 
superficially,  to  be  attached  by  its  deep  or  posterior  border, 
is  the  lacunar  hgament  (Gimbernat's  hgament)  whose  apex  is 
at  the  pubic  tubercle,  its  base  at  the  internal  boundary  of  the 
femoral  (crural)  ring  with  the  femoral  vein  in  close  apposition. 
Passing  further  laterally  the  ilio-psoas  muscle  overlaps  the 
bony  pelvic  margin  on  its  internal  aspect.  Upon  the  anterior 
surface  of  the  muscle  lie  the  external  iliac  artery  and  vein. 
On  the  left  side  the  vein  is  internal  and  posterior  to  the  artery 


THE   PELVIC  BASIN   AND    CONTENTS  21 

while  on  the  right  side  the  artery  nearly  covers  it.  The  round 
ligament  crosses  the  lower  portion  of  the  artery  and  lies  anterior 
to  it  just  before  the  ligament  enters  the  abdominal  inguinal 
ring  (internal  inguinal  ring).     On  the  left  side,  3  to  5  cm.  above 


Fig.  8. — Pelvic  inlet  and  female  pelvic  organs  in  a  woman  of  forty  who  has  borne 

children.     {After  Edgar.) 

the  level  of  the  inguinal  Hgament,  the  ilio-psoas  muscle  and  the 
iliac  vessels  are  crossed  by  the  iliac  portion  of  the  sigmoid  colon 
where  the  latter  turns  downward  over  the  ilio-psoas  to  become 
the  pelvic  colon.     Still  further  around  the  bony  circumference 


22  ANATOMY 

of  the  inlet  the  external  iliac  vessels  are  crossed  superficially  by 
the  ovarian  artery  and  vein  where  the  latter  pass  into  the  pelvis 
to  enter  the  broad  Hgament. 

Opposite  the  lumbo-sacral  joint  the  common  iliac  artery 
terminates  in  the  external  iliac  and  hypogastric.  At  this  point 
the  ureter  crosses  superficially  and  lies  on  the  anterior  surface 
of  the  hypogastric  artery  as  this  passes  downward  in  the  pelvis. 
Still  further  posteriorly  the  superior  hemorrhoidal  artery  crosses 
the  common  iliac  artery  and  vein  and  passes  downward  into 
the  pelvis  to  the  left  of  the  sacral  promontory.  The  obturator 
nerve  and  lumbo-sacral  cord  pass  deeply  beneath  the  vessel  to 
reach  the  pelvic  cavity.  Over  the  sacral  promontory  runs  the 
middle  sacral  artery.  The  left  posteiro-lateral  portion  of  the 
pelvic  brim  is  also  covered  by  the  mesentery  of  the  pelvic 
colon  which  is  attached  by  its  roots  on  a  line  extending  up  the 
ilio-psoas  muscle  to  the  bifurcation  of  the  common  iliac,  then 
down  again  over  the  sacral  promontory.  On  the  right  side  the 
terminal  portion  of  the  ileum  overlaps  the  pelvic  brim  and 
covers  the  iliac  vessels  and  the  ilio-psoas  muscle. 

That  portion  of  the  small  intestine  beginning  2  to  4  meters 
from  the  duodenum  and  which  possesses  the  longest  mesentery, 
sometimes  has  some  of  its  coils  in  the  pelvic  cavity,  and  it  and 
its  mesentery  are  superficial  to  and  overlie  all  other  structures 
at  the  posterior  part  of  the  circumference  of  the  pelvic  brim. 

The  peritoneum  as  a  whole  may  be  traced  from  the  anterior 
abdominal  wall  as  it  passes  downward  over  the  intestinal  surface 
of  the  bladder.  Where  the  bladder  and  uterus  come  into  rela- 
tion at  the  level  of  the  superior  end  of  the  cervix,  the  peritoneum 
is  reflected  upward  over  the  anterior  surface  of  the  uterus,  thus 
forming  the  vesico-uterine  excavation.  Laterally  this  layer  of 
peritoneum  forms  the  antero-inferior  layer  of  the  broad  liga- 
ment. The  peritoneum  passes  over  the  fundus  and  runs  down- 
ward over  the  posterior  uterine  wall  to  and  below  its  vaginal 
attachment,  extending  over  the  posterior  vaginal  wall  for  i 
or  2  cm.     This  layer  extends  laterally  to  form  the  postero- 


THE  PELVIC   CONTENTS  23 

superior  layer  of  the  broad  ligament.  After  leaving  the  pos- 
terior vaginal  wall  the  peritoneum  is  again  reflected  upward 
onto  the  rectum  thus  forming  the  recto-uterine  excavation  of 
Douglas.  The  lateral  boundaries  of  this  excavation  are  folds 
of  peritoneum  which  on  either  side  run  from  the  corresponding 
side  of  the  rectum.  Within  these  folds  are  found  the  recto- 
uterine muscle  (sacro-uterine  ligament). 

One  gains  a  better  conception  of  the  relation  of  the  pelvic 
viscera  to  the  peritoneum  by  imagining  all  the  former  as  sup- 
ported in  their  proper  positions  by  their  true  fibro-muscular 
ligaments,  while  the  peritoneum  has  been  draped  from  above 
like  a  loose  sheet  and  tucked  carefully  around  all  the  folds  and 
into  all  the  crevices.  All  the  peritoneum- covered  organs  are 
developed  outside  their  serous  covering,  and  all  remain  outside 
the  peritoneum  excepting  the  ovary  which  has  a  modified 
endothelial  outer  covering  but  no  distinct  peritoneal  coat. 
The  above-mentioned  folds  of  peritoneum  comprise  the  false 
ligaments  of  the  viscera,  the  true  Hgaments  underlying  them. 

PELVIC  CONTENTS 

Having  traced  the  structures  at  the  pelvic  inlet,  its  contents 
as  a  whole  may  be  noted  as  they  appear  from  above.  It  will 
be  seen  that  the  entire  small  pelvis  is  divided  into  anterior  and 
posterior  compartments  by  a  transverse  vertical  partition 
consisting  of  the  uterus  and  broad  ligaments.  This  partition 
extends  from  one  to  the  other  lateral  pelvic  wall,  and  from  about 
the  level  of  the  pelvic  brim  above  to  the  pelvic  diaphragm  or 
floor  below. 

The  uterus  occupies  the  center  of  this  partition  with  its 
fundus  pointing  antero-superiorly.  The  uterine  tubes  running 
laterally  under  the  superior  margin  of  the  broad  ligaments  are 
visible  at  this  time. 

In  the  posterior  larger  compartment  are  seen  loops  of  small 
intestine  and  the  pelvic  colon.     Upon  lifting  out  the  small 


24 


ANATOMY 


intestine  the  posterior  surface  of  the  uterus  and  broad  ligaments 
is  exposed.  Depending  from  each  broad  ligament  is  the  ovary, 
which  the  uterine  tube  loosely  encircles  superiorly  and  ex- 
ternally. That  portion  of  the  rectum  above  the  pelvic  dia- 
phragm is  exposed  and  the  recto-uterine  excavation  recognized, 
the  latter  bounded  by  the  recto-uterine  ligaments  laterally, 
the  peritoneal  covered  portion  of  the  posterior  vaginal  fornix 
and  uterus  anteriorly,  and  the  rectum  posteriorly. 


P'iG.  9. — Pelvic  contents  seen  from  above.     {After  Edgar.) 


The  pelvic  colon  may  be  traced  from  above  downward. 
Beginning  at  the  pelvic  margin,  it  passes  obliquely  downward 
and  toward  the  right  lateral  pelvic  wall,  then  loops  backward 
and  to  the  left  to  the  mid-line,  where  opposite  the  third  sacral 
vertebra  it  turns  directly  downward  as  the  rectum. 

The  smaller  anterior  compartment  contains  the  bladder  and 
sometimes  a  few  coils  of  small  intestine.     By  tilting  the  uterus 


THE   PELVIC   CONTENTS 


25 


backward  its  free  mobility  is  noted  and  the  fundus  of  the 
bladder  can  be  seen.  At  the  level  of  the  reflexion  of  the  peri- 
toneum from  the  posterior  bladder  wall  onto  the  uterus,  the 


Fig.  10. — Nerve  supply  of  female  genital  organs.     {After  Edgar.) 

utero-vesical  excavation  is  noted,  bounded  laterally   by   the 
utero-vesical  ligaments. 

The  antero-inferior  layer  of  the  broad  ligament  is  exposed 
and  the  ridge  produced  by  the  round  Kgament  under  it  can  be 
observed. 


26 


ANATOMY 


THE  PELVIC   CONTENTS   CONSIDERED   INDIVIDUALLY 

THE  UTERUS 

The  uterus  is  a  thick-walled  muscular  sac  formed  by  the 
fusion  of  the  Miillerian  tubes.  It  is  lined  throughout  by  a 
mucous  coat  and  a  part  of  its  outer  surface  is  covered  by  peri- 
toneum. The  uterus  consists  of  two  parts,  a  corpus  or  body 
and  a  cervix  or  neck,  which  are  united  by  the  isthmus. 


Fig.  II. — Sagittal  section  of  nulliparous  uterus.     {After  Edgar.) 

The  corpus  uteri  is  entirely  supra-vaginal.  It  has  an  antero- 
inferior or  vesical  surface  and  a  postero-superior  or  intestinal 
surface.  The  vesical  surface  is  relatively  flat  and  completely 
covered  by  that  layer  of  peritoneum  which  at  the  level  of  the 
isthmus  is  reflected  onto  the  posterior  surface  of  the  bladder. 
As  its  name  impHes  it  looks  forward  and  downward  when  the 


THE   UTERUS 


27 


bladder  is  empty.     When  the  bladder  is  distended  it  looks 
directly  anteriorly  or  even  antero-superiorly. 

The  intestinal  surface  is  convex  and  is  covered  by  peritoneum 
which  continues  downward  onto  the  posterior  surface  of  the 
supra-vaginal  cervix.     Of  the  three  margins,  the  superior  is 


Fig.  12, — Sagittal  section  of   multiparous   uterus.     (After  Edgar.) 


known  as  the  fundus,  is  convex,  and  corresponds  to  that  portion 
of  the  body  superior  to  the  attachments  of  the  uterine  tubes. 

The  lateral  margins  extend  downward  from  the  entrance  of 
the  tubes  and  correspond  to  the  space  between  the  attachment 
of  the  two  layers  of  the  broad  ligaments.  The  tubes,  ovarian 
arteries,  veins,  nerves,  and  lymphatics  all  pass  to  and  from  the 
body  of  the  uterus  at  its  lateral  margins  between  the  layers  of  the 
broad  ligament. 


28 


ANATOMY 


The  cervix  uteri  comprises  all  that  portion  of  the  uterus  in- 
ferior to  the  isthmus.  In  nulliparae  it  constitutes  about  one- 
half  the  length  of  the  uterus,  while  in  women  who  have  borne 
children  its  relative  length  is  less  and  that  of  the  body  greater. 
The  cervix  pierces  the  vaginal  vault  obliquely  backward  and 
downward,  the  vaginal  wall  being  attached  to  it  in  a  line  about 
5  mm.  in  thickness. 


Fig.  13. — Anterior  surface  of  nulliparous  uterus.     {After  Edgar.) 


That  portion  of  the  cervix  superior  to  the  line  of  the  vaginal 
attachment  is  known  as  the  supra-vaginal  cervix;  that  portion 
projecting  into  the  vagina  as  the  portio-vaginalis  or  infra- 
vaginal  cervix. 

The  anterior  surface  of  the  supra-vaginal  portion  has  no 
peritoneal  coat  and  is  in  relation  with  the  posterior  surface  of 
the  bladder  to  which  it  is  loosely  attached  by  connective  tissue. 


THE   UTERUS 


29 


The  posterior  surface  of  the  supra-vaginal  cervix  is  covered 
by  peritoneum  and  faces  the  recto-uterine  excavation. 

The  infra-vaginal  cervix  points  toward  the  posterior  vaginal 
wall  and  the  hollow  of  the  sacrum.  The  posterior  lip  of  the 
infra-vaginal  cervix  is  longer  than  the  anterior.  Just  above 
the  vaginal  attachment,  upon  either  side  of  the  posterior  wall, 
is  found  the  uterine  attachment  of  the  recto-uterine  ligament. 


Fig.  14. — Anterior  surface  of  multiparous  uterus. 


The  cavity  of  the  uterus  in  the  virgin  is  only  a  potential  cavity 
the  anterior  and  posterior  walls  of  which  lie  in  contact  with  each 
other. 

The  lower  end  of  the  cavity  of  the  body  of  the  uterus  is 
separated  from  the  cervical  canal  by  a  constriction  at  the  in- 
ternal orifice  of  the  uterus  (internal  os).  Below  this  the 
cervical   canal   presents  a   fusiform  dilatation   followed  by  a 


30 


ANATOMY 


second  constriction  at  the  external  orifice  (external  os).  In 
virgins  the  external  orifice  is  nearly  circular  but  in  parous  women 
it  is  a  transverse  slit.  The  entire  uterine  canal  is  about  6 
cm.  in  length  in  nulliparae  and  7  cm.  in  multiparae.  Its  greatest 
width  is  from  3  to  4  cm.  The  direction  of  the  uterine  axis  is 
upward  and  forward  from  the  external  orifice,  with  an  anterior 
concavity  at  the  level  of  the  internal  orifice. 


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Fig.  15. — Normal  endometrium.  This  section  shows  the  normal  proportion 
of  glandular  to  interstitial.  This  corresponds  fairly  well  with  the  description 
found  in  some  text-books  to  the  effect  that  the  area  between  glands  should  equal 
that  of  the  glands  themselves. 

The  coats  of  the  uterus  from  without  inward  are  serous, 
muscular,  and  mucous.  The  serous  coat  at  the  lateral  uterine 
margins  is  continuous  with  the  peritoneal  folds  forming  the 
broad  ligaments. 

The  muscular  coat  is  thick  and  constitutes  the  greater  portion 
of  the  uterine  wall.     Roughly  it  is  made  up  of  three  layers: 


THE  UTERUS  3 I 

(a)  a  thick  outer  layer  continuous  with  the  muscle  fibers  of  the 
uterine  ligaments  and  tubes;  (b)  a  middle  layer  which  is  the 
heaviest  and  whose  fibers  interlace  in  all  directions  but  are 
grouped  in  small  circular  bundles  about  the  internal  uterine 
orifice  and  the  uterine  mouths  of  the  tubes;  (c)  an  inner  layer 
of  longitudinal  fibers,  many  of  which  terminate  in  the  cervix. 
These  muscular  layers  can  be  separated  in  the  pregnant  uterus 
but  are  difficult  to  distinguish  in  the  non-pregnant.  The  uterine 
mucosa  is  continuous  above  with  that  Hning  the  tubes,  and 
below  with  the  stratified  squamous  vaginal  epithelium  covering 
the  inferior  end  of  the  cervix.  There  is  no  submucosa,  the 
mucous  coat  lying  directly  on  the  muscular  and  fitting  the 
irregularities  produced  by  the  bundles  of  muscle  fibers.  The 
mucous  coat  lining  the  body  of  the  uterus  is  smooth  and  pale 
and  is  known  as  the  endometrium.  It  is  lined  with  cyHndrical 
ciliated  epithelium  and  studded  with  straight  tubular  glands, 
some  of  which  dip  into  the  muscle  underlying  the  mucosa. 

The  mucous  coat  of  the  cervical  canal  is  thicker  and  denser 
than  that  of  the  body  and  possesses  both  tubular  and  racemose 
glands  which  secrete  a  glairy  mucus. 

The  cervical  lining  is  thrown  into  a  series  of  ridges  and  in- 
tervening furrows  known  as  the  arbor  vitae.  These  correspond 
to  the  arrangement  of  the  inner  muscular  layer  and  radiate  late- 
rally and  upward  from  the  median  anterior  and  posterior  lines. 

The  blood  supply  to  the  uterus  is  from  the  uterine  and  ovarian 
arteries,  both  of  which  anastomose  with  the  artery  of  the  round 
ligament. 

The  uterine  artery,  a  branch  of  the  hypogastric,  runs  between 
the  layers  of  the  broad  ligament  near  its  base  and  reaches  the 
uterus  at  the  level  of  the  internal  uterine  orifice.  Here  it 
turns  sharply  upward  giving  off  numerous  branches  in  its 
course,  and  below  the  level  of  the  uterine  end  of  the  tube  it 
anastomoses  with  the  ovarian.  That  portion  of  the  uterine 
artery  which  runs  upward  along  the  lateral  margin  of  the  uterus 
is  sometimes  termed  the  utero-ovarian.     It  gives  off  numerous 


32  ANATOMY 

branches  which  penetrate  the  muscular  wall  of  the  uterus  by 
running  between  the  bundles  of  muscle  fibers  and  terminate  just 
beneath  the  epithelium  lining  the  mucous  coat. 

The  ovarian  artery  is  a  branch  of  the  abdominal  aorta,  and 
from  the  level  of  the  pelvic  brim  it  passes  between  the  layers  of 
the  broad  ligament  near  its  upper  margin,  but  inferior  to  the 
tube  and  ovary.  The  uterine  veins  are  two  or  three  in  number 
and  empty  into  the  hypogastric.  The  veins  accompanying 
the  ovarian  artery  form  the  pampiniform  plexus  in  the  broad 
ligament  and  terminate  in  the  ovarian  vein.  The  cerebro- 
spinal nerves  are  derived  from  the  third  and  fourth  sacral, 
the  sympathetic  supply  comes  from  the  hypogastric  plexus 
and  forms  a  ganglion  on  the  uterine  artery  where  it  crosses 
the  ureter. 

THE   OVARY 

The  ovary  is  a  pearly  white  almond-shaped  organ  which  is 
suspended  from  the  posterior  surface  of  the  broad  ligament  by 
the  mesovarium.  It  averages  3  to  4  cm.  in  length,  2  to  3 
cm.  in  width,  and  i  to  i)^  cm.  in  thickness.  It  has  two  surfaces, 
the  lateral  of  which  lies  at  the  upper  portion  of  the  obturator 
internus  muscle  where  there  is  present  a  depression  known  as 
the  ovarian  fossa.  At  the  upper  border  of  this  fossa  are  the 
external  iUac  vessels,  posterior  are  the  ureter  and  uterine  artery, 
while  crossing  its  floor  are  the  obturator  vessels  and  nerve. 
The  mesial  surface  of  the  ovary  looks  toward  the  uterus.  The 
anterior  or  mesovarial  margin  looks  forward  and  outward. 
The  posterior  free  margin  looks  backward  and  inward  toward 
the  rectum.  The  outer  part  of  the  upper  margin  of  the  broad 
ligament  (infundibulo  pelvic  ligament)  extends  from  the  upper 
extremity  of  the  ovary  to  the  pelvic  brim  as  the  suspensory  liga- 
ment of  the  ovary. 

From  the  inferior  extremity  of  the  organ  the  true  ovarian 
Ugament  runs  inward  between  the  layers  of  the  broad  ligament 
to  be  attached  to  the  uterus  inferior  to  the  tubes. 


THE    UTERINE    TUBES  33 

In  the  adult  the  ovarian  surface  is  studded  with  vesicles, 
the  vesicular  ovarian  follicles  (Grafhan  follicles),  and  it  presents 
numerous  scars  at  points  where  previous  "follicles  have  ruptured. 

The  surface  of  the  ovary  is  covered  by  a  single  layer  of 
cuboidal  cells  which  are  continuous  with  the  peritoneum  of  the 
mesovarium.  Beneath  this  layer  the  connective-tissue  stroma 
is  thickened  to  form  the  tunica  albuginea.  The  anterior  at- 
tached margin  of  the  ovary  presents  a  gap  between  the  layers  of 
the  mesovarium  which  is  known  as  the  hilum,  and  through 
which  the  ovarian  vessels,  nerves,  and  lymphatics  pass. 

The  substance  of  the  ovary  consists  of  two  portions.  The 
outer,  known  as  the  cortex,  contains  the  primary  ovarian  follicles 
and  their  mature  forms,  the  vesicular  ovarian  follicles,  which  are 
embedded  in  a  connective-tissue  stroma.  The  central  or  medul- 
lary portion  is  richer  in  blood-vessels  and  is  made  up  largely  of 
loose  connective  tissue,  with  a  few  unstriped  muscle  fibers 
which  are  continued  inward  from  between  the  layers  of  the 
mesovarium. 

The  ovarian  artery,  as  it  passes  beneath  the  ovary,  gives  off 
branches  which  enter  the  ovary  through  the  hilum.  The  veins 
from  the  ovary  pass  out  through  the  hilum  and  unite  with  those 
of  the  pampiniform  plexus  to  terminate  in  a  single  trunk  as  the 
ovarian  vein. 

The  lymphatics  of  the  ovary  communicate  freely  with  those 
of  the  uterus,  an  important  anatomical  fact  which  has  a  marked 
bearing  on  the  development  of  ovarian  abscess  as  the  result  of 
uterine  infection.  The  ovarian  and  uterine  lymphatics  unite 
and  accompany  the  ovarian  vein,  finally  terminating  in  the 
lateral  lumbar  lymph  glands. 

THE    UTERINE    TUBES 

The  uterine  tubes,  from  9  to  12  cm.  in  length,  extend  out- 
ward from  their  point  of  junction  with  the  uterus,  and  are 
contained  within  the  peritoneal  fold  which  forms  the  superior 
3 


34  ANATOMY 

margin  of  the  broad  ligament.  All  their  coats  are  continuous 
with  those  of  the  uterus  itself.  Each  tube  consists  of  (a) 
a  uterine  portion  extending  through  the  uterine  wall,  (b)  an 
isthmus  or  narrow  medial  portion,  (c)  an  ampulla  the  dilated 
outer  portion,  and  {d)  an  infundibulum  or  trumpet-shaped 
extremity.  The  infundibulum  terminates  in  a  series  of  proc- 
esses known  as  fimbriae,  some  of  which  come  into  contact  with 
the  posterior  surface  of  the  ovary  over  which  the  tube  curves, 
partially  encircling  it.  The  tubal  infundibulum  opens  into 
the  free  peritoneal  cavity  and  thus  establishes  a  communication 
between  this  cavity  and  the  open  air.  That  portion  of  the  broad 
ligament  which  contains  the  tube  and  extends  to  the  utero- 
ovarian  ligament  is  known  as  the  meso-salpinx.  Between  the 
layers  of  the  broad  ligament  comprising  the  meso-salpinx  run 
the  vessels,  nerves,  and  lymphatics  of  the  tube,  and  vestiges 
of  embryological  structures  known  as  the  epo-oophoron  and 
para-oophoron  are  found  within  it.  The  hydatid  of  Morgagni 
is  a  small  cyst  usually  attached  to  one  of  the  tubal  fimbria. 
The  narrowest  portion  of  the  lumen  of  the  tube  admits  but  a 
very  fine  probe  and  is  found  in  the  uterine  part.  The  mucous 
coat  is  arranged  in  folds  which  are  simple  in  their  disposition 
at  the  isthmus  but  become  more  complex  at  the  ampulla. 
There  are  no  glands  in  the  mucous  coat,  whose  epithelium  is 
ciliated  and  lies  directly  upon  the  muscular  coat.  Diverticula 
from  the  lumen  sometimes  occur  while  accessory  tubes  and 
secondary  ostia  are  occasionally  found. 

External  to  the  mucosa  is  found  the  muscular  coat  which 
consists  of  an  inner  circular  and  outer  longitudinal  layer.  The 
tunica  adventitia  is  a  vascular  connective-tissue  coat  which 
lies  between  the  external  muscular  layer  and  the  peritoneum, 
and  is  continuous  with  the  sub-serous  tissue  of  the  broad 
ligament. 

The  peritoneal  coat  covers  about  four-fifths  of  the  tubal 
circumference,  that  portion  of  the  tube  which  corresponds  to 
the  attachment  of  the  meso-salpinx  having  no  serous  covering. 


THE   URINARY  BLADDER  35 

The  arteries  come  from  the  ovarian  and  uterine  and  freely- 
anastomosing  branches  pass  between  the  layers  of  the  meso- 
salpinx.    The  veins  correspond  to  the  arteries. 

The  lymphatics  accompany  those  from  the  fundus  uteri  and 
terminate  in  the  lumbar  lymph  glands.  The  nerves  are  de- 
rived from  the  hypogastric  plexus. 

THE  URINARY  BLADDER 

The  urinary  bladder  is  essentially  a  thin-walled,  distensible, 
muscular  sac,  lined  with  mucous  membrane  and  partially  covered 
by  peritoneum.  When  distended  the  female  bladder  is  ovoid, 
its  transverse  diameter  being  greater  than  its  vertical.  When 
empty  the  superior  surface  becomes  concave,  the  vesical  cavity 
being  reduced  to  a  T-shaped  fissure. 

The  distended  bladder  has  a  superior,  anterior,  posterior, 
and  two  lateral  surfaces,  the  latter  being  somewhat  indistinct. 
The  anterior  surface  has  no  serous  coat  and  extends  from  the 
urachus  to  the  internal  urethral  orifice,  looking  downward  and 
forward  toward  the  pubis  from  which  it  is  separated  by  the 
prevesical  space  filled  with  fatty  connective  tissue.  The 
superior  or  intestinal  surface  is  entirely  covered  with  peritoneum 
and  looks  upward  toward  the  abdominal  cavity.  The  Hne  of 
demarcation  between  the  superior  and  anterior  surface  is  a 
transverse  line  drawn  through  the  vesical  extremity  of  the 
urachus,  but  there  is  no  distinct  division  between  the  superior 
and  posterior  faces.  The  posterior  or  uterine  surface  extends 
downward  to  the  internal  urethral  orifice,  there  uniting  with 
the  anterior  surface.  The  upper  portion  of  the  bladder  is 
covered  by  peritoneum  and  corresponds  to  the  vesico-uterine 
excavation.  The  lower  portion  of  the  posterior  surface  has  no 
serous  investment,  and  is  attached  to  the  anterior  face  of  the 
supra- vaginal  cervix  and  anterior  vaginal  wall  by  a  thin  exten- 
sion of  the  endo-pelvic  fascia.  The  upper  portion  of  the  lateral 
surfaces  is  covered  by  peritoneum,  the  lower  by  fatty  connec- 


36  ANATOMY 

tive  tissue  bearing  the  vesical  vessels  and  nerves  and  separat- 
ing the  bladder  from  the  levator  ani  muscles. 

The  ureters  enter  the  bladder  wall  at  the  junction  of  its 
posterior  and  lateral  surfaces.  They  pass  obliquely  through 
the  vesical  wall  for  about  2  cm.  before  terminating  in  the  ureteral 
orifices,  one  on  either  side  at  the  superior  angles  of  the  vesical 
trigone.  The  completely  distended  bladder  may  rise  as  high 
as  the  umbilicus  but  ordinarily  the  vesical  fundus  does  not  ex- 
tend above  the  superior  margin  of  the  pubis.  When  the  bladder 
is  over-distended,  the  anterior  portion  of  the  superior  surface 
looks  anteriorly  so  that  the  anterior  wall  viewed  in  over-dis- 
tension is  not  covered  and  lies  directly  in  contact  with  the  an- 
terior abdominal  wall.  The  urachus  and  obliterated  foetal 
portion  of  the  hypogastric  arteries  are  known  as  the  middle 
and  lateral  umbilical  ligaments  respectively. 

Strands  of  the  endo-pelvic  fascia  pass  from  the  bladder  to 
the  pubis  and  are  known  as  the  middle  pubo-vesical  ligaments. 
Laterally,  strands  of  the  same  fascia  pass  from  the  bladder  to 
the  tendinous  arch  of  the  levator  ani  muscles  upon  either  side 
and  these  are  known  as  the  lateral  pubo-vesical  ligaments. 
On  the  posterior  surface  two  thickened  folds  of  connective 
tissue  passing  one  on  either  side  of  the  mid-line  are  termed 
the  vesico-uterine  ligaments.  In  the  infant  the  bladder 
occupies  a  position  relatively  higher  than  in  the  adult,  the 
internal  orifice  of  the  urethra  lying  behind  the  crest  of  the  pubes. 

The  interior  of  the  bladder  shows  a  pale  pink  mucosa,  which, 
except  at  the  trigone,  is  folded  into  numerous  ruga?  when  the 
bladder  is  empty  and  smoothed  out  when  it  is  distended. 

The  mucosa  of  the  trigone  is  at  all  times  smooth  and  pinker 
in  color  than  that  lining  the  remainder  of  the  bladder.  The 
outline  of  the  trigone  is  readily  seen,  a  transverse  ridge  lying 
between  the  ureteral  orifices  marking  its  base  while  its  apex 
lies  at  the  internal  urethral  orifice.  The  ureteral  orifices  are 
situated  at  the  summit  of  the  ureteral  papilla).  Projecting 
obliquely  backward  and  outward  from  each  papilla  is  another 


THE   URINARY  BLADDER 


37 


distinct  ridge  which  marks  the  course  of  the  ureters  through 
the  bladder  wall. 

The  peritoneal  and  mucous  coats  already  mentioned  cover 
the  muscle  wall,  each  being  separated  from  the  latter  by  a  layer 
of  areolar  tissue  which  forms  the  sub-serous  and  sub-mucous 
coats  respectively.  The  muscle  wall  is  composed  of  three 
layers,  an  internal  and  external  longitudinal  and  a  middle 
circular.  The  circular  layer  makes  up  the  greater  portion  of 
the  entire  thickness  of  the  bladder  wall  and  at  the  internal 
urethral  orifice  it  forms  the  vesical  sphincter. 


^Ih.       '•  MBMUhiirTT" 

■JM 

i^ 

X'SH 

f" 

If 

■p) 

'  '''Wk    (i 

ii\ 

Kj 

V  '.S^-^P^ 

\i>j 

Fig.  1 6. — Anterior  portion  of  internal  surface  of  the  pelvis.     Showing 
middle  pubo- vesical  ligaments.     {After  Edgar.) 


The  chief  blood  supply  of  the  bladder  is  obtained  from  the 
superior  and  inferior  vesical  branches  of  the  hypogastrics.  The 
middle  hemorrhoidal,  vaginal,  and  uterine  arteries  give  off 
some  small  branches  which  reach  the  bladder  wall.  The 
veins  form  large  plexuses  on  the  external  surface  of  the  muscular 
wall  of  the  bladder  and  terminate  in  the  hypogastrics.  The 
lymphatics  anastomose  freely  beneath  the  mucous  coat,  are 
especially  well  developed  near  the  internal  urethral  orifice,  and 
drain  into  the  hypogastric  lymph  glands. 

The  cerebro-spinal  nerves  are  from  the  third  and  fourth 
sacral,  the  sympa  the  tics  from  the  hypogastric  plexuses. 


3^ 


ANATOMY 


THE   URETERS 


The  exact  course  of  the  ureters  is  of  the  utmost  importance  in 
pelvic  surgery.  Each  ureter  crosses  the  bifurcation  of  the 
common  iliac  vessel  of  its  own  side,  passes  over  the  pelvic 
brim  near  the  sacro-iliac  joint,  and  enters  the  pelvis  lying  on  the 


Fig.  17. — Relations  of  ureters,  uterine  artery  and  cervix.     (After  Edgar.) 


anterior  surface  of  the  hypogastric  artery.  On  the  lateral 
pelvic  wall  the  ureter  forms  the  posterior  boundary  of  the 
ovarian  fossa  on  the  obturator  internus.  After  reaching  the 
pelvic  diaphragm  it  runs  in  the  base  of  the  broad  ligament, 
passes  toward  the  median  line,  and  is  crossed  by  the  uterine 


THE  BROAD   LIGAMENTS  39 

artery  from  i  to  2  cm.  lateral  to  the  cervix.  At  this  point  it 
lies  inferior  to  the  artery  among  the  uterine  veins,  and  is 
immediately  above  the  lateral  vaginal  fornix.  It  then  enters 
the  bladder  wall  at  a  distance  of  from  33^  to  4  cm.  from  its 
fellow,  courses  obliquely  through  the  bladder  wall  from  i  to 
2  cm.,  and  terminates  at  the  ureteral  papilla.  The  pelvic 
ureter  is  constricted  at  a  point  just  above  its  vesical  orifice  and 
again  where  it  crosses  the  pelvic  brim,  and  just  above  each 
constriction  is  found  a  fusiform  dilatation. 

THE    UTERINE    LIGAMENTS 

The  uterine  (round)  ligaments  begin  at  the  lateral  margins 
of  the  uterus  anterior  and  just  inferior  to  the  tubes.  Each 
ligament  passes  laterally  between  the  layers  of  the  broad  liga- 
ment, making  a  slight  projection  under  its  anterior  fold.  It 
reaches  the  anterior  abdominal  wall  at  the  abdominal  inguinal 
ring.  There  it  curves  sharply  about  the  inferior  epigastric 
artery  and  passes  along  the  inguinal  canal  to  the  subcutaneous 
ring.  At  this  point  it  turns  downward  over  the  superior  margin 
of  the  pubic  bone  to  terminate  in  the  labium  majus.  In  its 
course  through  the  inguinal  canal  it  may  be  accompanied  by  a 
tube  of  peritoneum  known  as  the  vaginal  process,  a  foetal 
structure  which  sometimes  remains  open  in  adult  life.  The 
round  ligament  is  thickest  at  its  uterine  end  and  gradually 
becomes  thinner  to  its  termination.  It  is  composed  of  unstriped 
muscle  continuous  with  that  of  the  uterus.  The  artery  of  the 
round  ligament  is  a  branch  of  the  inferior  epigastric  which  runs 
in  the  ligament  toward  its  uterine  end,  where  it  anastomoses 
with  branches  from  the  ovarian  and  uterine. 

BROAD   LIGAMENTS 

The  broad  ligaments  have  been  described  previously  as  a 
double  layer  of  peritoneum  extending  from  the  uterine  margins 
laterally  to  the  pelvic  wall.     Within  them  are  found  the  uterine 


40 


ANATOMY 


tubes  superiorly,  with  their  vessels,  nerves,  and  lymphatics. 
Inferior  to  the  tube  are  the  ovarian  vessels,  nerves,  and  lymph- 
atics. Occupying  a  position  anterior  and  fairly  inferior  to 
the  ovarian  vessel  is  the  round  ligament.     The  tube,  round 


Fig.   1 8. — Diagrammatic  section  of  broad  ligament.     {After  Morris.) 


ligament,  ovarian  artery  and  true  ligament  of  the  ovary  ap- 
proach each  other  as  they  near  the  uterus.  The  superior  margin 
of  the  broad  Hgament  external  to  the  ovary  contains  the  ovarian 
vessels,  and  is  known  as  the  suspensory  ligament  of  the  ovary  or 


THE    PELVIC   FASCIA  41 

infundibulo-pelvic  ligament,  in  distinction  to  the  true  ovarian 
ligament  which  ruus  from  the  inferior  mesial  end  of  that  organ 
to  the  uterus.  In  the  bases  of  the  broad  ligaments  are  found 
the  uterine  vessels  and  ureters  whose  relations  have  been 
described,  and  surrounding  them  is  the  connective  tissue  known 
as  the  parametrium. 


Fig.   19. — Broad  ligament  and  its  contents  seen  from  the  front.     {After  Sappey.) 

PELVIC   FASCIA 

The  fascia  of  the  pelvis  minor  is  a  continuation  of  the  iliac 
fascia.  It  makes  bony  attachments  as  it  passes  downward 
over  the  linea  terminalis  (ilio-pectinea  line)  to  cover  the  obtura- 
tor muscle.  Shortly  below  the  pelvic  brim,  it  splits  into  three 
layers  along  the  line  of  origin  of  the  levator  ani  muscle.  The 
external  layer  continues  down  the  pelvic  wall  on  the  internal 
surface  of  the  obturator  internus  muscle  and  is  known  as  the 
obturator  fascia.  The  middle  layer  covers  the  external  and 
inferior  surface  of  the  levator  ani  and  is  known  as  the  inferior 
fascia  of  the  pelvic  diaphragm.  These  two  layers  thus  line 
the  outer  and  inner  walls  of  the  ischio-rectal  fossa.  The 
internal  layer  covers  the  internal  and  superior  face  of  the  levator 
ani  and  is  known  as  the  superior  fascia  of  the  pelvic  diaphragm. 


42 


ANATOMY 


It  is  in  direct  contact  with  the  pelvic  viscera,  each  of  which  in 
turn  receives  from  it  a  sheath  or  layer.  These  various  layers, 
which  are  split  off  from  the  superior  fascia  of  the  pelvic  dia- 


FiG.  20. — Diagram  of  the  pelvic  fascia.     (Afkr  Morris.) 


phragm  and  from  the  pelvic  fascia  proper  at  the  tendinous 
arch  of  the  levator  ani  muscle,  form  the  connective-tissue  linings 
and  attachments  of  the  pelvic  viscera,  and  collectively  are 
known  as  the  endo- pelvic  fascia. 


REFERENCES 


REFERENCES 


43 


McMURRICH,  J.  P.— The  Development  of  the  Human  Body.     A  Manual  of 

Human  Embryology.     Philadelphia,  19 15. 
DEAVER,  JOHN  B. — Surgical  Anatomy.     A  Treatise  on  Human  Anatomy  in 

Its  Application  to  the  Practice  of  Medicine  and  Surgery.     Vols,  i  and  iii. 

Philadelphia,  1899  and  1908. 
FALK,  J.  J. — Beitrage  zur  Lehre  von  der  Innervation  des  Uterus  und  der  Vagina. 

Zeitsch.  f.  Geb.  und  Gyn.,  1913,  Ixxiv,  881. 


CHAPTER  II 
PHYSIOLOGY      l 

The  primary  function  of  the  genitaha  of  both  sexes  is  the 
reproduction  of  species.  In  women  there  are  a  number  of 
associated  physiological  activities  which  may  be  perverted 
and  thus  lead  to  their  classification  as  gynaecological  diseases, 
or  the  performance  of  the  physiological  acts  necessary  for 
reproduction  may  be  productive  of  injuries  which  are  recognized 
as  gynaecological  lesions.  As  an  example  of  the  first  class  may 
be  mentioned  extremely  painful  menstruation;  of  the  second, 
laceration  of  the  pelvic  floor  during  labor. 

The  physiological  reproductive  functions  of  the  female 
mammal  are  ovulation,  reception  of  the  seminal  fluid,  its  trans- 
mission to  the  place  of  union  between  the  spermatozoid  and 
ovule,  retention  of  the  fertilized  ovule  until  the  embryo  is  able 
to  exist  independently,  expulsion  of  the  embryo  from  the  uterus, 
and  the  return  of  the  genital  organs  to  their  condition  previous 
to  impregnation.  In  the  human  female  another  function,  men- 
struation, is  added. 

The  actual  physiological  functions  of  the  reproductive  organs 
of  the  human  female  are  therefore  in  their  order;  menstruation 
and  ovulation;  reproduction  including  impregnation,  gestation, 
and  labor;  and  involution. 

Menstruation  has  been  defined  as  *'a  periodical  discharge  of 
blood  and  mucus  from  the  female  genital  organs,  taking  place 
every  28  days  from  puberty  to  the  menopause,  excepting  during 
gestation  and  lactation.''  Although  the  above  definition  covers 
the  clinical  phases  of  menstruation  it  is  subject  to  many 
exceptions  without  deviation  from  the  normal.  Menstruation 
need  not  necessarily  occur  every  28  days,  some  women  men- 

44 


MENSTRUATION  45 

struating  every  three  weeks  and  others  at  much  greater  in- 
tervals; while  still  others  are  habitually  irregular  and  suffer 
no  inconvenience  therefrom.  During  the  first  three  months  of 
pregnancy,  menstruation  may  continue  to  take  place  owing  to 
the  fact  that  the  decidua  vera  and  decidua  capsularis  do  not 
fuse  until  the  fourth  month.  The  absence  of  menstruation 
during  lactation  is  but  slightly  more  common  than  its  occur- 
rence, and  some  women  menstruate  as  regularly  during  lactation 
as  at  any  other  interval  between  pregnancies. 

The  duration  of  normal  menstruation  is  from  three  to  six 
days,  although  an  occasional  individual  menstruates  but  one 
or  two  days  at  each  period  throughout  her  active  sexual  life, 
and  remains  perfectly  well.  The  amount  of  blood  lost  at  each 
period  can  only  be  estimated,  and  each  woman  is  a  law  unto 
herself  in  this  respect.  One  peculiar  characteristic  of  normal 
menstrual  blood  is  its  failure  to  clot.  Many  widely  different 
reasons  have  been  given  to  account  for  this,  but  it  seems  almost 
certain  that  during  its  passage  through  the  endometrium  some 
substance  has  been  added  which  inhibits  clot  formation,  as  a 
mixture  of  menstrual  blood  with  freshly  drawn  blood  remains 
uncoagulated. 

Menstruation  begins  at  about. the  time  of  puberty  at  which 
period  conception  is  rendered  possible  through  the  maturation 
of  the  ovules  and  their  discharge  from  the  ovaries  by  the  rupture 
of  the  follicles  which  contain  them,  and  it  generally  ceases  with 
the  cessation  of  this  function  of  the  ovaries.  The  age  for  the 
onset  of  menstruation  in  the  north  temperate  zone  varies 
from  10  to  14  years,  but  instances  of  earlier  menstruation  are 
common,  while  it  is  not  unusual  to  have  the  first  period  delayed 
until  16  or  18.  Instances  of  true  precocious  menstruation  are 
known  and  are  not  to  be  confused  with  the  bloody  vaginal  dis- 
charge which  occasionally  takes  place  in  new-born  female  in- 
fants. Menstruation  may  recur  with  perfect  regularity  after 
the  function  is  once  established,  or  there  may  be  irregularities 
during  the  first  year  or  two  following  its  onset.     It  seems  to  be 


46  PHYSIOLOGY 

established  at  a  somewhat  earher  age  in  city  girls  than  in  those 
living  in  rural  districts,  and  the  age  of  onset  appears  to  bear  a 
distinct  relation  to  the  degree  of  mental  development  of  the 
individual. 

That  period  in  the  life  of  the  individual  woman  at  which  the 
reproductive  functions  permanently  cease  is  known  as  the  meno- 
pause. It  is  marked  by  the  cessation  of  menstruation  and  the 
gradual  establishment  of  atrophic  changes  in  all  the  genital 
organs. 

The  age  at  which  menstruation  normally  ceases  varies  within 
wide  limits.  An  occasional  instance  of  cessation  before  the  40th 
year  is  noted  but  regularity  may  persist  until  after  50.  Final 
cessation  most  frequently  occurs  at  45,  46,  or  47,  and  as  a  rule, 
cessation  of  menstruation  takes  place  at  an  earlier  age  in  women 
who  began  to  menstruate  late,  and  later  in  those  who  began 
to  menstruate  early.  Irregularities  are  likely  to  have  been 
noticed  for  some  years  preceding  this  event,  and  it  is  only  oc- 
casionally that  menstruation  ceases  abruptly  and  without  pre- 
vious warning  in  the  way  of  missed  periods,  scanty  flow,  or 
alternation  between  scanty  flow  and  profuse  blood  loss. 
Nervous  phenomena  during  this  time  are  quite  as  striking  as  the 
menstrual  irregularity,  and  they  usually  persist  for  a  year  or 
more  after  menstruation  has  entirely  ceased.  Headache, 
"nervousness,"  "hot  flashes,"  flushing  of  the  face,  palpitation 
of  the  heart,  and  profuse  perspiration  are  the  most  noticeable. 
The  cause  of  these  evidences  of  irritability  of  the  central  nervous 
system  is  unknown,  but  presumptively  they  are  due  to  cessation 
of  ovarian  function  and,  more  than  Hkely,  to  failure  of  an 
internal  ovarian  secretion. 

Regarding  the  ultimate  cause  of  menstruation  nothing  has 
been  defmitely  established,  although  certain  associated  facts 
are  well  understood.  Thus  menstruation  ceases  after  complete 
removal  of  both  ovaries.  The  ovaries,  therefore,  are  necessary 
in  order  that  menstruation  may  occur,  and  as  menstrual  cessa- 
tion after  complete  double  ovariotomy  is  instantaneous,  as 


MENSTRUATION  47 

distinguished  from  the  gradual  cessation  at  the  normal  meno- 
pause, it  is  evident  that  some  function  of  the  ovaries,  which  is 
suddenly  checked  by  their  removal,  dies  out  gradually  at  the 
age  of  normal  cessation.  In  the  past,  ovulation  has  been  as- 
sumed to  be  the  fundamental  cause  of  menstruation,  and  it 
has  been  taken  for  granted  that  ovulation  occurs  as  a  regular 
periodical  process,  an  individual  ovulation  being  responsible 
for  each  individual  menstruation.  A  few  recent  writers  even 
support  this  view,  but  the  abdominal  cavity  has  been  opened  so 
frequently  in  the  last  few  years  that  many  opportunities  have 
been  afforded  to  inspect  the  ovaries  at  varying  intervals  both 
before  and  after  menstruation,  and  it  seems  to  be  definitely 
established  that  ovulation  does  not  occur  with  the  clock-like 
regularity  of  menstruation.  In  addition,  ovulation  could  only 
occur  one-half  as  often  if  one  ovary  were  removed,  still  less 
often  if  one  ovary  and  half  of  the  other  had  been  removed,  etc. ; 
the  fact  is  that  menstruation  is  as  regular  with  only  a  portion 
of  one  ovary  remaining  as  with  both.  While  ovulation,  there- 
fore, probably  is  responsible  for  menstruation,  each  menstrual 
period  is  not  produced  by  its  own  individual  ovulation.  The 
recent  discoveries  of  active  physiological  function  by  the  pro- 
duction of  an  internal  secretion  in  such  organs  as  the  adrenals, 
thyroid,  and  pituitary  body  are  suggestive  of  similar  functions 
on  the  part  of  the  ovaries  and  the  known  facts  in  no  way  con- 
tradict this  idea,  indeed  it  likely  will  be  found  that  a  true  hor- 
mone is  produced  in  the  ovary  which  furnishes  the  required 
chemical  stimulus  to  menstruation.  Some  of  the  latest  re- 
searches point  to  the  corpus  luteum  as  the  original  source  of 
a  menstrual  hormone,  while  others  make  it  seem  probable  that 
the  interstitial  ovarian  cells  are  responsible  for  it. 

Certain  changes  of  a  histological  character  which  take  place 
in  the  uterus  at  the  time  of  menstruation  are  also  the  subject 
of  some  dispute.  The  following  facts,  however,  are  unques- 
tioned: (i)  The  uterus  as  well  as  all  the  other  pelvic  organs  is  en- 
gorged with  blood.     (2)  There  are  extravasations  of  blood  under 


48  PHYSIOLOGY 

the  superficial  epithelium  lining  the  uterine  cavity.  (3)  Minute 
portions  of  this  epithelium  are  cast  off  with  the  menstrual  blood. 
The  chief  point  of  discussion  concerns  the  method  by  which 
blood  extravasation  takes  place.  Some  authorities  hold  that 
the  superficial  epithelium  is  largely  cast  off,  and  that  the  capil- 
laries   rupture   because   of   increased   vascular   tension,    while 


m 


Fig.  2 1 . — Menstrual  endometrium.  This  section  siiows  both  the  premenstrual 
congestion  and  the  escape  of  blood.  The  glandular  elements  are  here  unchanged 
but  the  interglandular  tissue  is  very  loose,  oedematous,  and  in  some  areas 
saturated  with  blood.  The  more  finely  stippled  areas  beneath  the  surface  and 
at  the  lower  left  are  masses  of  red  blood  cells.  At  the  lower  left  the  blood  is 
escaping. 

others  believe  that  diapedesis  of  red  cells  takes  place  without 
injury  to  the  vessel  wall.  Future  studies  of  uteri  removed 
during  menstruation  should  definitely  settle  this  point,  the 
number  of  observations  at  present  being  too  limited  to  permit 
of  any  permanent  conclusion. 

That  there  is  a  regular  evolution  of  the  endometrium,  pro- 


OVULATION  49 

ceeding  through  well-defined  stages  from  one  menstrual  flow 
to  the  next,  has  been  well  established  by  the  histological  ex- 
amination of  the  endometrium  of  uteri  removed  at  various 
times  during  the  intermenstrual  interval.  So  definite  is  this 
that  some  authorities  consider  the  entire  28  days  as  nothing 
more  nor  less  than  a  true  menstrual  cycle,  of  which  the  period 
of  bloody  discharge  is  but  a  manifestation  of  one  of  the  stages. 
Whether  or  no  the  tubes  regularly  contribute  to  the  discharge 
of  menstrual  blood  is  doubtful,  but  they  have  at  times  been 
observed  to  do  so,  both  by  the  author  and  by  others. 

Since  physiological  functions  are  painless,  menstruation 
should  have  no  definite  painful  symptoms,  but  in  civilized 
women  there  is,  with  very  few  exceptions,  some  discomfort  at 
this  time.  Ordinarily  there  is  more  or  less  backache  and  a 
bearing-down  sensation  in  the  hypogastric  regions  and,  in 
many  instances,  rhythmic  pain  or  cramps  which  the  patient 
locates  just  posterior  to  the  pubis.  It  is  difiicult  to  say  just 
how  much  discomfort  is  physiological,  but  generally  speaking, 
sufficient  disturbance  to  incapacitate  the  patient  may  be  con- 
sidered as  exceeding  the  normal.  Associated  with  this  dis- 
comfort there  is  malaise  and  nervous  irritability.  Ordinarily 
the  flow  itself  is  darker  than  normal  blood  and  it  contains  an 
admixture  of  mucus  which  has  its  origin  in  the  glands  of  the 
cervix.  This  cervical  mucous  discharge  precedes  and  follows 
menstruation  for  a  day  or  two  and  usually  is  free  enough  to 
be  perceptible  as  a  moderate  leucorrhea. 

Ovulation  consists  in  the  ripening  of  an  ovule  and  its  discharge 
from  the  ovary.  One  ovule  is  present  in  each  follicle,  the  fol- 
licles existing  in  the  ovaries  from  the  time  of  embryonic  develop- 
ment and  having  their  origin  in  the  egg  cords  of  embryonic  life. 
While  the  actual  number  of  follicles  in  each  ovary  is  indeter- 
minate it  has  been  estimated  at  35,000,  and  in  the  ovaries  of 
the  mature  woman  they  can  be  seen  in  all  stages  of  development. 

The  process  of  ripening  is  evidenced  by  enlargement  of  the 
follicle  through  the  accumulation  in  its  interior  of  an  increasing 
4 


50 


PHYSIOLOGY 


amount  of  the  fluid  known  as  the  liquor  follicuH.  Pressure 
atrophy  of  the  ovarian  substance  overlying  the  follicle  continues 
until  the  latter  finally  projects  about  the  surrounding  surface  of 
the  ovary.  The  external  wall  of  the  foUicle  becomes  pro- 
gressively thinner  until  increased  pressure  from  within  results 
in  rupture  of  the  wall  and  discharge  into  the  abdominal  cavity 
of  the  folUcle  and  liquor  folUculi,  together  with  the  mass  of 
cells  known  as  the  cumulus  oophorus  or  discus  proHgerus  which 
surrounds  the  ovule.  The  after-history  of  unimpregnated 
ovules  is  unknown;  whether  many  of  them  die  in  the  abdominal 
cavity  and  are  absorbed,  whether  carried  into  the  uterine 
tubes  to  undergo  the  same  fate,  or  whether  they  are  discharged 
into  the  uterus,  is  uncertain.  With  rupture  of  the  foUicle  there 
occurs  a  hemorrhage  into  the  cavity  which  remains,  giving  it 
the  appearance  of  a  small  haematoma.  Later  this  takes  on  a 
yellow  color  from  the  presence  of  lutein  cells  whose  exact  origin 
is  unknown  but  from  which  the  name,  corpus  luteum,  is  de- 
rived. Connective  tissue  soon  makes  its  appearance  in  the 
corpus  luteum,  and  should  pregnancy  not  occur  a  small  white 
scar  forms  upon  the  surface  of  the  ovary  to  mark  the  site  of 
rupture  of  the  follicle,  the  whole  process  occupying  a  period  of 
three  or  four  weeks.  Should  pregnancy  occur,  the  changes 
above  outlined  are  more  pronounced,  the  corpus  luteum  attains 
a  larger  size,  and  three  or  four  months  will  elapse  before  the 
corpus  luteum  is  entirely  replaced  by  connective  tissue.  The 
microscopic  appearance  corresponding  to  the  above-described 
gross  changes  are  minutely  described  in  obstetric  text-books. 
The  time  elapsing  between  successive  ovulations  is  not  definitely 
known  and,  as  has  been  indicated  in  the  preceding  section,  its 
exact  relation  to  menstruation  is  uncertain.  In  the  author's 
experience  corpora  lutea  in  the  same  stage  of  development 
never  have  been  found  simultaneously  in  both  ovaries,  but  the 
abdomen  has  often  been  opened  soon  after  menstruation  without 
the  discovery  of  any  evidence  of  recent  ovulation.  It  seems 
probable  that  the  increased  congestion  incidental  to  menstrua- 


PREGNANCY  AND   LABOR  5 1 

tion  may  provoke  rupture  of  a  follicle  which  is  already  ripe, 
but  there  is  no  known  reason  why  their  cyclic  periodicity  should 
coincide  unless  ovulation  is  regularly  periodical  and  the  men- 
strual hormone  really  is  a  product  of  the  corpus  luteum  at  some 
time  during  the  involution  of  that  body. 

Pregnancy  and  Labor, — Pregnancy  and  its  corollaries,  labor 
and  abortion,  are  productive  of  a  large  proportion  of  all  gynaeco- 
logical disorders. 

Pregnancy  begins  with  the  fertiKzation  of  the  ovule  and  ends 
with  the  discharge  of  the  ovum  from  the  uterus,  regardless  of 
whether  this  occurs  prematurely  or  at  full  term.  In  the  human 
being  the  point  of  fertiKzation  or  union  of  the  spermatozoid 
with  the  ovule  has  not  been  definitely  determined,  but  by  most 
authorities  it  is  considered  to  be  the  interior  of  the  uterine  tube, 
whence,  it  is  assumed,  the  ovule  has  been  floated  by  a  stream  of 
peritoneal  serum  diverted  in  this  direction  by  the  activity  of 
the  cihated  tubal  epithelium.  After  fertilization  the  ovum  is 
carried  into  the  uterus  by  the  tubal  epitheHum,  where  it  becomes 
embedded  in  the  endometrium,  probably  by  its  parasitic 
qualities,  and  it  remains  in  the  uterus  until  complete  develop- 
ment, providing  premature  expulsion  does  not  take  place.  The 
time  elapsing  between  impregnation  and  expulsion  of  the  full 
term  foetus  is  approximately  280  days,  after  which  time  auto- 
matic contractions  of  the  uterine  muscles  occur  and  result  in  the 
discharge  from  the  uterus  of  the  foetus,  placenta,  and  membranes. 

Various  theories  have  been  propounded  to  explain  why  the 
spontaneous  activity  of  the  uterus  is  set  up  at  the  expiration 
of  this  particular  period  of  time,  but  none  of  them  are  adequate 
unless  they  take  into  consideration  the  law  of  the  survival  of 
the  fittest.  If  the  human  foetus  were  expelled  much  before  this 
regular  time  it  would  be  lost  by  reason  of  insufficient  develop- 
ment; if  pregnancy  were  protracted  much  beyond  the  allotted 
time,  death  of  the  foetus  would  be  inevitable  because  of  its 
excessive  size.  The  tendency,  therefore,  has  been  to  preserve 
the  offspring  of  those  women  whose  gestation  periods  corre- 


52  PHYSIOLOGY 

sponded  most  closely  to  the  time  required  for  the  development  of 
a  foetus  sufficiently  developed  to  be  viable,  but  not  so  large  as  to 
jeopardize  its  life  during  delivery,  and  this  must  be  considered 
as  the  ultimate  origin  of  the  280-day  gestation  period  even 
though  a  placental  hormone  is  proven  to  be  the  immediate 
cause  of  uterine  contractions.  The  rhythmic  contractions  ol 
the  uterus,  which  result  in  the  expulsion  of  its  contents  at  the 
time  of  labor,  also  are  perceptible  throughout  pregnancy  and 
for  several  days  after  delivery.  During  pregnancy  these  con- 
tractions are  painless  and  have  no  effect  on  the  cervix.  After 
labor,  in  multiparas,  they  assist  in  keeping  the  uterus  empty  and 
are  often  painful.  Strictly  normal  pregnancy  rarely  produces 
gynecological  disease,  but  its  premature  interruption  frequently 
results  in  incomplete  evacuation  of  the  uterus  followed  by  de- 
composition or  infection  of  the  retained  products  of  conception. 
Neither  is  involution  so  perfect  after  abortion  or  after  full  term 
labor,  the  uterus  remaining  large  and  soft  and  its  ligaments 
failing  to  regain  their  tonicity,  this  combination  many  times 
being  responsible  for  displacement  and  prolapse.  Even  after 
delivery  at  full  term  the  same  series  of  events  may  ensue  if 
infection  takes  place  or  the  uterus  is  not  completely  evacuated. 
The  cervix  may  be  deeply  lacerated  and  the  pelvic  floor  injured 
by  rapid  delivery  or  through  abnormal  position  or  presentation, 
or  by  relative  disproportion  between  the  foetus  and  the  maternal 
soft  parts,  and  the  greater  part  of  the  plastic  surgery  of  the  pelvic 
organs  is  made  necessary  by  such  injuries  sustained  during  the 
course  of  a  process  which  ought  to  be  purely  physiological. 

REFERENCES 

SCHMOTKIN.  — Klinische  Untersuchunjijen  iiber  die  Menstruation  bei  gesunden 

Indixiduen.     Arch.  f.  Gyn.,  191 2,  xcvii,  495. 
BELL. — Menstruation   and   Its   Relation   to  the   Calcium   Metabolism.     Proc. 

Roy.  Soc.  Med.,  1907-8,  i;  Obs.  b"  Gyn,  Sec,  291. 
ENGELMANN. — Age  of  First  Menstruation  on  the  North  American  Continent. 

Tr.  Am.  Gyn.  Soc,  1901,  xxvi,  77. 
SCHMAUCH. —  Die  Schildriise  dcr  Frau  und  ihr  Kinfluss  auf  Menstruation  und 

Sclnvangerschaft.     Monals.  f.  Geh.  und  Gyn.,  1913,  xxxviii,  662. 


REFERENCES  53 

GOFFE. — -The  Biochemical  Function  of  the  Endometrium  in  the  Etiology  of 

Metrorrhagia  and  Menorrhagia.     N.  York  M.  J.,  1914,  c,  iii. 
SCHAEFFER. — Ueber  Beginn,  Dauer  und  Erloschen  der  Menstruation.     Sta- 

tistische  Mitteilungen  iiber  10,500  Falle  aus  der  gynakologischen  Praxis. 

Monats.f.  Geb.  undGyn.,  1906,  xxiii,  169. 
CANTONI. — Ueber  der  Blutveranderungen  wahrend  der  Menstruation.     Arch. 

f.  Gyn.,  1913,  xcix,  541. 
LENZ. — Vorseitige    Menstruation,    Geschlechtsreife   und    Entwicklung.     Arch. 

f.  Gyn.,  1913,  xcix,  67. 
SCHICKELE.— Die  Nervosen  Ausfallsercheinungen   der  normalen  und   friih- 

seitigen  Menopause  in  ihren  Beziehungen  zur  inneren  Sekretion.     Hand 

b.  d.  Neurol.  1913,  Iv,  434;  AbsL  J.nternat.  Abs.  Surg.,  May,  1914,  509. 
SCHROEDER. — Ueber  die  zeitlicken  Beziehungen  der  Ovulation  und  Menstrua- 
tion.    Arch.  f.  Gyn.,  1913,  cl. 
CLARK. — The  Anatomical  Basis  of  Ovulation  and  Menstruation.     Tr.   Am. 

Gyn.  Soc,  191 1,  xxxvi,  265. 
BENTHIN. — Ovarium  und  innere  Sekretion.     Therap.  d.  Gegenw.,  1914,  Iv,  193. 
CULBERTSON,   CAREY. — Physiology  of   Internal   Secretions   of   the   Ovary. 

Int.  Abst.  Surg.,  July,  1914,  i. 
EDITORIAL. — The  Functions  of  the   Corpus  Luteum.     /.  A.  M.  A.,   1914, 

Ixiii,  32. 
HOSKINS. — The  Interrelation  of  the  Organs  of  Internal  Secretion.     Am.  J. 

Med.  Soc,  191 1,  cxli,  535. 
YOUNG. — The  Structure  of  the  Stroma  of  the  Endometrium  and  Its  Bearing 

on  the  Menstrual  Changes.     Brit.  Med.  J.,  1910,  ii,  12 14. 
RUGE. — Ueber  Ovulation,  Corpus  Luteum  und  Menstruation.     Arch.  /.  Gyn., 

1913,  c,  20. 
SCHROEDER. — Neue   Ausichten  uber   die   Menstruation   und   ihr   zeitliches, 

Verhalten  zur  Ovulation.     Monats.f.  Geb.  und  Gyn.,  1913,  xxxviii,  i. 
CHISHOLM. — Menstrual   Molimina.     /.    Obst.    &    Gyn.    Brit.    Emp.,    1913 

xxiii,  288. 
HITSCHMANN  AND  ADLER.— Der  Bau  der  Uterusschleimhaut  des  geschlecht- 

sreifen  Menstruation.     Monats.  f.  Geb.  und  Gyn.,  1908,  xxvii,  i. 
MARCOTTY. — Ueber   das    Corpus   Luteum  Menstruationis  und  das   Corpus 

Luteum  Graviditatis.     Ein  Beitrag  zur  Lehre  von  der  Ovulation  und  ]SIen- 

struation.     Arch.  f.  Gyn.,  1914,  ciii,  63. 
FENGER,  F.— Distinction  between  the  Corpus  Luteum  of  Ovulation  and  the 

True  Corpus  Luteum  of  Pregnancy.     Preliminary  Report.     /.  Am.  Med. 

Asso.,  1914,  Ixii,  1249. 
DICK  AND  CURTISS.— Concerning  the  Functions  of  the  Corpus  Luteum  and 

Some  Allied  Problems.     Surg.,  Gyn.  b'  Obst.,  1912,  xv,  588. 
KIUTSI. — Ueber  die  Innere   Sekretion  des   Corpus  Luteum.     Monats.  }.  Geb. 

undGyn.,  1912,  xxxvi,  399. 
LOEB. — The  Physiology  and  Pharmacology  of  the  Excised  Human  Uterus. 

Am.  J.  Obst.,  1915,  Ixxi,  209. 


CHAPTER  III 
SYMPTOMATOLOGY  AND  DIAGNOSIS 

Before  proceeding  to  any  measures  for  the  treatment  of 
gynaecologic  disease  or  injury,  a  diagnosis  of  all  the  pathological 
conditions  both  within  and  without  the  pelvis  should  be  at- 
tempted, and  this  should  be  as  complete  as  possible.  The 
inquiry  should  not  end  with  the  pelvic  organs,  but  should 
extend  to  a  careful  consideration  of  the  entire  body  since  it  is 
only  by  a  searching  examination  that  serious  and  even  fatal 
blunders  can  be  avoided.  Four  distinct  sources  of  information 
are  available  in  arriving  at  a  diagnosis:  (i)  Family  history. 
(2)  Personal  history.  (3)  Present  subjective  symptoms.  (4) 
Objective  physical  signs. 

Family  History. — While  the  family  history  relatively  is  of 
less  importance  in  gynaecology  than  it  is  in  general  medicine, 
it  often  throws  light  on  some  obscure  conditions  which  pre- 
sent themselves.  Thus  a  patient  who  has  no  history  of  a 
preceding  infection  may  present  herself  with  evidences  of  tubal 
or  ovarian  inflammation,  chronic  in  type,  whose  etiology  might 
be  entirely  overlooked  but  for  a  well-marked  family  history  of 
predisposition  to  tuberculosis.  While  the  question  of  family 
predisposition  toward  the  development  of  mahgnancy  is  un- 
settled, its  possibilities  cannot  be  overlooked,  and  the  influence 
of  family  tendencies  in  explaining  delayed  or  precocious  men- 
struation and  late  or  early  menopause  is  quite  within  the  range 
of  probabihty.  Again,  the  mimicry  of  pelvic  disease  may  be 
so  accurate  as  to  deceive  the  closest  observer  and  may  be 
explained  only  when  a  well-marked  family  history  of  neuras- 
thenia, hysteria,  or  insanity  is  obtained. 

54 


HISTORY  55 

Personal  History. — The  personal  history  preceding  the  sup- 
posed onset  of  the  present  illness  is  of  great  importance  and 
should  be  obtained  in  the  most  accurate  form  possible.  In 
obtaining  this  it  generally  is  wise  to  allow  the  patient  to  tell 
her  story  in  her  own  way,  and  later  to  bring  out  the  saHent 
points  by  a  system  of  cross  examination.  It  is  rare  to  see  a 
patient  who  is  so  well  informed  as  to  give  an  accurate  account 
of  the  past  events  which  bear  upon  her  present  illness,  and 
matters  of  major  importance  may  be  overlooked  at  the  first 
consultation  that  are  readily  ascertained  subsequently.  For 
this  reason,  a  second,  or  even  third  consultation  is  judicious 
in  obscure  cases  when  the  physical  examination  is  unsatis- 
factory. In  the  cross  examination  the  patient  should  be  held 
down  to  categorical  answers  so  far  as  possible.  General 
statements,  such  as  that  a  previous  labor  was  very  difficult, 
that  she  has  had  ''womb  trouble"  or  "ovarian  disease"  for 
many  years,  etc.,  may  be  wholly  misleading.  The  duration 
of  the  labor  and  its  mode  of  termination  should  be  inquired 
into  and  the  reason  for  the  patient's  belief  in  the  existence 
of  disease  of  the  uterus  or  ovaries  definitely  ascertained,  when 
frequently  it  will  be  found  that  the  presumed  difficult  dehvery 
was  normal  and  that  the  only  justification  for  a  beHef  in  the 
existence  of  pelvic  disease  is  pelvic  discomfort  or  moderate 
dysmenorrhea.  On  the  other  hand,  histories  of  repeated  mis- 
carriages, prolonged  confinement  in  bed  after  labor  or  abortion, 
and  sudden  profuse  leucorrhea  shortly  after  marriage  followed 
by  chronic  pelvic  pain  with  occasional  exacerbations,  are  almost 
pathognomonic  in  their  significance. 

The  actual  data  which  should  be  secured  are,  the  social  status; 
whether  married,  single,  or  widowed;  if  married,  the  number 
and  character  of  labors  and  miscarriages;  the  age  at  which 
menstruation  first  appeared;  the  menstrual  habit  previous  to 
the  present  illness;  and  past  illnesses  of  any  kind,  whether  local 
or  general.  All  of  these  questions  should  be  gone  into  sys- 
tematically and  should  lead  up  gradually  to  the  present  illness, 


56  SYMPTOMATOLOGY   AND   DIAGNOSIS 

concerning  which  the  necessity  for  accurate  information  is  at 
least  as  great.  Concerning  the  illness  itself  there  should  be 
ascertained  the  time  and  mode  of  its  onset  and  an  account  of 
the  evolution  of  the  symptoms  up  to  the  present  time.  Some 
patients  possess  a  habit  of  irrelevancy  which  leads  them  to 
discuss  anything  and  everything  before  taking  up  their  chief 
ailment,  while  others  act  the  part  of  unwilHng  witnesses  in  an 
evident  attempt  to  withhold  information.  Such  patients  should 
be  met  by  a  firm  request  that  they  state  just  why  they  applied 
for  consultation. 

GYNECOLOGIC  PAIN 

Some  present  themselves  because  of  plain  objective  signs 
such  as  a  mass  protruding  from  the  vulva,  abdominal  enlarge- 
ment, or  visible  discharge  from  the  vagina,  but  the  greater 
number  of  gynaecological  patients  apply  for  relief  from  sub- 
jective symptoms  which  they  describe  as  disagreeable  sensa- 
tions or  actual  pain.  It  should  be  remembered  that  painful 
sensations  are  entirely  subjective,  and  the  interpretation  of 
their  importance  demands  the  greatest  circumspection  and 
widest  general  medical  knowledge  on  the  part  of  the  examiner. 
The  exact  location  of  pain  as  well  as  its  character  must  be 
determined;  whether  it  is  burning,  cutting,  sharp,  or  dull; 
and  a  constant  effort  should  be  made  to  estimate  the  patient's 
susceptibility  to  pain,  since  the  greatest  difference  exists  in 
this  respect.  Some  women  are  so  constituted  that  the  most 
trivial  discomfort  is  interpreted  as  severe  pain,  while  the  capacity 
of  others  to  bear  suffering  without  complaint  is  remarkable. 
It  also  should  be  borne  in  mind  that  the  actual  severity  of  the 
pain  bears  no  necessary  relation  to  the  gravity  of  the  disease 
which  produces  it.  Many  .serious  gyniccologic  diseases,  such 
as  ovarian  cystoma,  uterine  fibroma,  and  early  carcinoma,  are 
essentially  painless,  while  a  j^rolapsed  ovary  or  chronically 
inflamed  tube  may  be  the  source  of  great  suffering.  The  pain 
produced  by  gynaicologic  lesions  usually  is  fairly  well  localized 


PAIN 


57 


either  in  the  neighborhood  of  the  organs  involved,  or  in  the 
termination  of  the  sensory  nerves  connected  with  the  same 
segment  of  the  spinal  cord  as  the  nerves  from  those  organs. 

Gynaecologic  pain  is  most  frequently  present  in  that  portion 
of  the  trunk  below  the  level  of  the  umbilicus,  and  it  may  extend 
down  the  thighs  both  anteriorly  and  posteriorly.  The  most 
common  sites  for  such  pain  are  thehypogastrio  regions  anteriorly 
and  the  sacral  region  posteriorly,  the  latter  in  the  form  of  the 


Fig.  2  2. — Diagrammatic  representa-  Fig.  23. — Diagrammatic  represen- 
tion  of  location  of  backache  from  dis-  tation  of  location  of  anterior  abdomi- 
ease  of  the  pelvic  organs.  nal  pain  from  disease  of  pelvic  organs. 


familiar  sacral  backache.  While  pain  above  the  umbilicus  may 
have  its  origin  in  pelvic  disease,  it  should  be  viewed  with  sus- 
picion as  more  likely  to  be  caused  by  a  lesion  above  the  pelvic 
inlet.  A  marked  exception  to  this  rule  is  the  characteristic 
pain  about  the  costal  margin  which  so  frequently  is  present  in 
tubal  pregnancy  with  severe  hemorrhage.  Backache  at  the 
waist  Hne  which  so  commonly  is  remarked  by  gynaecologic 
patients  usually  is  either  static  or  neurasthenic,  when  it  bears 


58  SYMPTOMATOLOGY  AND   DIAGNOSIS 

no  further  relation  to  pelvic  disorder  than  that  the  constantly 
recurring  pelvic  discomfort,  or  the  strained  position  which  the 
patient  assumes  on  standing,  may  be  responsible  for  the 
neurosis  in  the  first  instance,  or  the  static  disorder  in  the 
second. 

So-called  reflex  pain  in  the  head,  thorax,  or  epigastrium 
should  not  be  accepted  as  reflex  in  its  origin  until  a  careful 
examination  of  the  painful  area  and  its  surroundings  has  re- 
vealed no  evidence  whatever  of  underlying  disease.  Reflex 
arcs  ordinarily  are  short  and  are  well  represented  by  rectal 
tenesmus  in  cystitis  and  vesical  tenesmus  in  hemorrhoids  or 
fissure  of  the  anus. 

Anatomically  speaking,  pain  arising  from  disease  at  and  about 
the  vulva  is  likely  to  be  felt  in  the  parts  affected  and  in  their 
immediate  vicinity.  Pain  arising  from  disease  of  the  vagina 
is  referred  to  that  locality.  Pain  from  disease  of  the  cervix  is 
felt  in  the  sacrum.  Pain  having  its  origin  in  the  uterus  is  felt 
in  the  sacral  region  posteriorly  and  in  the  median  line  low  down 
above  the  pubis  anteriorly.  Pain  from  disease  of  the  tubes  and 
ovaries  usually  is  located  on  the  side  affected  and  directly 
above  the  pubis,  although  it  may  extend  a  short  distance  down 
either  of  the  corresponding  thighs  and  sometimes  as  high  as  the 
crest  of  the  ilium.  The  subjective  symptom  of  pain  should 
not  be  accepted  as  evidence  of  gross  disease  unless  supported 
by  other  and  more  tangible  evidence. 

As  stated  above,  some  patients  are  extremely  sensitive  to 
pain,  and  ordinary  trivial  discomfort  from  minor  functional 
disturbances  may  be  interpreted  as  severe  pain  by  such  in- 
dividuals. More  particularly,  pain  in  a  given  location  should 
not  be  construed  as  evidence  of  disease  of  the  important  organs 
in  that  region  unless  there  are  distinct  objective  signs  of  such 
disease.  Many  healthy  ovaries  have  been  resected  or  removed 
for  presumed  ovarian  pain,  when  a  more  careful  examination 
would  have  revealed  an  eroded  cervix  with  lymphangitis  in 
the  base  of  the  broad  ligaments  or  a  varicocele  of  the  pampini- 


LEUCORRHEA  59 

form  plexus.  It  is  desirable  always  to  keep  in  mind  that 
localities  giving  rise  to  pain  may  be  fairly  well  mapped  out  by 
the  distribution  of  the  pain,  but  not  organs. 

The  type  of  pain  suffered,  while  not  pathognomonic,  is  of 
assistance  in  arriving  at  some  conclusion  as  to  its  origin.  The 
smarting,  burning  pain  of  urethritis,  vulvitis,  and  vaginitis  is 
quite  characteristic,  as  is  the  lancinating  pain  in  acute  pelvic 
peritonitis,  the  rhythmic  labor-Hke  pain  of  spasmodic  or  ob- 
structive dysmenorrhea  and  sub-mucous  myoma,  the  Kttle 
colicky  pain  of  leaking  tubal  pregnancy,  and  the  intense 
anguish  of  final  rupture  with  profuse  hemorrhage;  while  the 
dragging  in  the  hypogastrium  and  low  sacral  backache  are 
precisely  what  one  might  expect  from  a  heavy,  retroverted,  and 
prolapsed  uterus. 

Leucorrhea. — Leucorrhea  may  be  considered  both  as  a  sub- 
jective symptom,  and  as  an  objective  sign  since  the  patient 
describes  it  as  she  feels  it,  while  the  examiner  detects  it  by  both 
touch  and  sight.  Normally  there  is  a  Hmited  amount  of  dis- 
charge from  the  female  genitaha  consisting  of  a  very  thin 
mucoid  material  from  the  body  and  fundus  of  the  uterus  mixed 
with  the  thick,  tenacious,  colorless  mucus  from  the  cervix,  a 
small  quantity  of  secretion  from  the  vaginal  fornices,  and  the 
secretion  from  the  greater  vestibular  glands  at  the  vulva. 

The  secretion  from  the  uterus  and  vagina  is  practically 
odorless,  but  decomposition  of  retained  blood,  necrotic  tumors, 
and  carcinomatous  tissue  gives  rise  to  a  foul  odor  which,  in  the 
case  of  advanced  cancer,  is  extremely  oft'ensive. 

The  quantity  of  discharge  under  normal  circumstances  is 
so  small  as  to  be  scarcely  perceptible  as  a  distinct  discharge, 
and  it  serves  to  keep  the  vagina  and  vaginal  outlet  moist. 
The  reaction  of  the  uterine  secretion  is  alkaline  while  that  from 
the  vagina  is  sHghtly  acid.  The  quantity  of  the  discharge 
may  be  changed,  sometimes  by  trivial  circumstances,  and  at 
others  by  well-marked  disease.  Increase  in  quantity  may  be 
produced  by  any  circumstance  which  stimulates  the  glands  to 


6o  SYMPTOMATOLOGY   AND   DIAGNOSIS 

increased  activity,  or  by  a  disease  process  which  produces 
exudate  from  surfaces  that  under  normal  circumstances  are 
non-secreting. 

Congestion  of  the  endometrium,  whether  this  be  due  to  a 
mechanical  change  Hke  retroversion,  physiologic  activity  as  in 
sexual  excitement,  or  pathologic  disturbance  in  other  organs 
as  inflammation  of  the  tubes,  is  productive  of  increased  activity 
of  the  uterine  glands  and  a  corresponding  increase  in  the  quan- 
tity of  uterine  discharge.  Very  marked  increase  in  the  cervical 
secretion  is  sometimes  present  without  any  pathological  con- 
dition being  found  to  account  for  it,  and  some  general  disorders, 
such  as  anaemia,  sometimes  are  accompanied  by  leucorrhea. 
A  patient's  complaint  of  leucorrhea  ought  always  to  lead  to 
an  attempt  to  ascertain  not  only  its  character  and  amount, 
but  its  source. 

A  purulent  discharge  having  its  origin  at  the  vulva  should 
lead  to  a  suspicion  of  gonorrhea,  although  it  may  be  due  to  a 
non-specific  vulvitis  which  is  found  much  more  frequently  in 
children  than  in  adults. 

Purulent  discharge  originating  in  the  vagina  may  likewise 
be  due  to  gonorrhea,  or  it  may  be  senile  and  trophic  in  character. 

A  distinctly  purulent  discharge  from  the  cervix  may  be  due 
to  gonorrhea,  to  an  unhealed  laceration,  to  cervical  erosion, 
or  to  septic  infection  of  the  cervical  or  uterine  glands. 

Long-standing  purulent  discharge  issuing  from  the  cervix 
almost  invariably  originates  in  the  cervix,  and  l^ut  rarely  from 
the  body  of  the  uterus,  as  has  been  so  long  taught.  In  case 
there  is  any  doubt  on  this  point  a  dry  tampon  may  be  placed 
over  the  external  uterine  orifice  and  allowed  to  remain  for  24 
hours.  The  character  of  the  discharge  accumulating  on  that 
portion  of  the  tampon  immediately  under  the  orifice  will  de- 
termine its  origin,  as  cervical  discharge  is  mixed  with  the  viscid 
mucus  while  that  from  the  enHomotrium  is  thin  and  much 
less  mucoid  in  character. 

Microscopic   examination   of   leucorrheal   discharge    reveals 


MENSTRUAL   DISORDERS  6 1 

gonococci  if  the  patient  has  acute  gonorrhea,  but  chronic 
gonorrhea  may  be  present  and  no  gonococci  be  found  even 
after  repeated  examinations.  Latent  gonorrhea  may  persist 
for  many  years  in  the  urethra,  in  the  para-urethral  ducts,  in 
the  greater  vestibular  glands,  and  in  the  cervical  glands,  and 
by  its  irritation  keep  up  a  continuous  leucorrheal  discharge 
from  any  of  these  sources. 

The  character  of  the  discharge  may  be  modified  by  an  in- 
creased secretion  from  one  section  of  the  genital  tract,  other 
portions  being  normal  but  by  reason  of  this  increase  not  con- 
tributing their  relative  proportions.  Most  frequently  it  is 
changed  by  the  addition  to  it  of  pus  from  infection  about  the 
vulva,  vagina,  or  cervix.  It  may  be  blood  stained  from 
abraded  surfaces,  erosion  of  the  cervix,  unhealed  laceration  of 
the  cervix,  carcinoma  of  the  cervix,  polypi  in  the  cervix  or 
uterus,  intense  inflammatory  action  anywhere  from  the  fundus 
uteri  to  the  vulva,  or  senile  changes  in  the  endometrium  and 
vagina  which  deprive  the  deep  layers  of  their  superficial 
covering  of  epithelium. 

In  conclusion  it  should  be  borne  in  mind  that  leucorrhea  is 
always  a  symptom  whose  cause  is  to  be  sought  and  never  a 
disease  to  be  treated  as  such,  and  too  much  emphasis  cannot 
be  placed  on  the  fact  that  leucorrhea  and  endometritis  are  not 
synonymous  terms. 

MENSTRUAL   DISORDERS 

In  the  consideration  of  menstrual  disorders  as  symptoms,  two 
distinct  points  should  be  kept  in  mind.  The  first  is  the  absence 
of  any  type  by  which  to  standardize  normal  menstruation, 
as  is  emphasized  in  the  paragraphs  devoted  to  that  subject; 
the  second  is  that  while  it  may  be  necessary  to  consider  men- 
strual disorders  as  entities  for  purposes  of  treatment  they  are 
nevertheless  wholly  symptomatic. 

Menstrual  disorders  are  classified  as  amenorrhea,  or  absence 
of  menstruation;  menorrhagia  or  profuse  regular  menstruation; 


62  SYMPTOMATOLOGY  AND   DIAGNOSIS 

metrorrhagia  or  irregularly  frequent  menstruation;  dysmenor- 
rhea or  painful  menstruation. 

Amenorrhea. — Very  scanty  menstruation  as  well  as  its  total 
absence  may  properly  be  included  under  this  heading,  since 
under  some  circumstances  scanty  menstruation  is  merely  a 
milder  form  or  earlier  stage  of  the  same  disturbance  which 
under  other  circumstances  may  cause  complete  suppression. 

It  is  self  understood  that  amenorrhea  is  normal  before  the 
onset  and  after  the  close  of  menstrual  life.  During  menstrual 
life  the  flow  is  physiologically  absent  throughout  pregnancy  and 
often  also  during  lactation. 

In  order  to  arrive  at  the  diagnostic  significance  of  amenorrhea 
in  a  given  case  it  is  well  to  remember  that  there  are  two  dis- 
tinct types :  in  one,  menstruation  has  never  occurred  although  the 
patient  is  well  past  the  age  at  which  it  usually  appears;  in  the 
other,  it  is  suspended  either  suddenly  or  gradually  after  a  period 
of  normal  menstruation. 

In  the  first  form,  which  may  be  called  primary  amenorrhea, 
some  deformity  or  mal-development  of  the  genital  organs  should 
be  suspected,  either  congenital  absence  of  the  ovaries  or  uterus, 
or  congenital  atresia  of  the  genital  tract  at  or  below  the  internal 
uterine  orifice.  In  congenital  absence  of  the  ovaries,  the  men- 
strual impulse  is  lacking;  in  congenital  absence  of  the  uterus, 
the  organ  from  which  the  flow  proceeds  is  missing.  In  atresia, 
both  impulse  and  flow  are  present  but  the  discharge  is  retained 
and  fails  to  make  its  appearance  at  the  vulva. 

In  considering  primary  amenorrhea,  attention  again  must 
be  called  to  the  great  variations  in  the  age  at  which  the  men- 
strual function  is  established.  It  is  not  unusual  to  see  perfectly 
robust  girls  of  1 6  or  1 8  in  whom  menstruation  has  not  made  its 
appearance  and  in  whom  examination  reveals  no  abnormality. 
Some  instances  are  also  known  in  which  menstruation  occurs  at 
very  irregular  periods  with  prolonged  intervals  of  amenorrhea 
during  which  the  patient  is  in  perfect  health.  In  one  case 
under  the  author's  observation,  menstruation  had  taken  place 


AMENORRHEA  63 

but  once  in  seven  years,  and  in  this  time  the  patient  had  been 
delivered  of  one  child  and  had  had  two  miscarriages. 

Secondary  amenorrhea,  when  occurring  suddenly  and  without 
symptoms  in  a  woman  previously  regular,  should  always  be 
looked  upon  as  due  to  pregnancy  until  the  contrary  is  proven. 
Psychic  influences,  especially  the  fear  of  pregnancy,  and  changes 
of  occupation  and  climate  may  cause  sudden  amenorrhea. 
Many  pupil  nurses  have  suppression  of  menstruation  ex- 
tending over  several  months  when  they  first  take  up  their 
training,  and  the  same  is  true  of  recently  arrived  immigrant 
girls. 

Sudden  suppression  of  menstruation,  when  accompanied  by 
symptoms  of  pelvic  inflammation,  is  most  frequently  due  to 
acute  endometritis.  The  popular  opinion  concerning  the 
effect  upon  menstruation  of  exposure  to  the  weather  and  wet- 
ting the  feet  has  some  foundation  in  fact,  and  when  suppression 
of  menstruation  occurs  under  these  circumstances  it  is  due  to 
an  acute  endometritis. 

Gradual  cessation  of  menstruation  is  brought  about  by  several 
widely  different  causes,  but  two  stand  out  with  especial  promi- 
nence: (i)  Anaemia,  primary  or  secondary;  (2)  that  curious 
type  which  is  closely  alHed  to  the  rapid  development  of  obesity 
in  young  women  and  which  probably  bears  some  relation  to 
hypo-pituitarism.  Gradual  cessation  is  also  observed  in 
severe  types  of  chronic  metritis,  and  either  partial  or  total 
cessation  may  follow  too  vigorous  curettage. 

Chlorosis,  which  is  so  common  in  young  women  factory 
workers,  develops  gradually,  but  complete  suppression  of 
menstruation  often  follows,  and  because  of  the  age  at  which 
chlorosis  occurs  it  is  the  form  of  primary  anaemia  most  frequently 
responsible  for  amenorrhea. 

Anaemia  secondary  to  any  of  the  chronic  diseases  may  lead  to 
a  gradual  cessation  of  menstruation,  under  which  circumstances 
the  amenorrhea  is  to  be  regarded  as  a  conservative  effort  on  the 
part  of  nature  to  preserve  the  patient's  strength  by  checking 


64  SYMPTOMATOLOGY  AND   DIAGNOSIS 

blood  loss.  Amenorrhea  in  tuberculous  patients  is  so  common 
as  to  be  noted  by  the  laity,  and  treatment  for  the  menstrual 
disorder  frequently  is  demanded  upon  the  erroneous  ground 
that  the  suppression  is  the  cause  of  the  general  ill  health.  Any 
of  the  chronic  wasting  diseases,  such  as  nephritis  and  diabetes, 
mahgnant  growths,  even  benign  tumors  such  as  ovarian  cysts 
of  large  size,  may  by  their  continued  progress  cause  amenorrhea, 
and  this  result  would  be  more  noticeable  if  they  occurred 
during  active  menstrual  life  as  frequently  as  does  tuberculosis. 

Dysmenorrhea. — A  moderate  feeling  of  discomfort  at  the 
menstrual  period  is  so  nearly  universal  that  it  may  be  considered 
normal,  and  no  hard  and  fast  line  can  be  drawn  between  normal 
and  abnormally  painful  menstruation.  In  an  individual  case, 
however,  a  sufficient  amount  of  pain  to  incapacitate  a  patient 
may,  from  a  cHnical  standpoint,  be  considered  abnormal. 

Many  classifications  of  dysmenorrhea  have  been  proposed, 
but  four  types  stand  out  clearly  whose  names  indicate  their 
character:  viz.,  obstructive,  congestive,  membranous,  and 
spasmodic. 

Painful  menstruation  due  to  obstruction  of  the  outflow  of 
blood  is  relatively  rare  and  is  quite  generally  due  to  congenital 
or  acquired  stenosis  of  the  cervix. 

Ordinary  anteflexion  does  not  produce  a  sufficient  degree  of 
stenosis  to  interfere  with  the  outflow  of  menstrual  blood,  since 
it  is  normally  discharged  in  a  very  slow  thin  stream,  but  if  the 
endometrium  is  so  diseased  or  menstruation  is  so  profuse  as  to 
lead  to  clotting  within  the  uterus,  a  normal  cervical  outlet 
may  be  too  small  to  permit  painless  passage  of  the  clots,  and 
a  relative  obstruction  is  then  present. 

Congestive  dysmenorrhea  almost  uniformly  is  present  in 
acute  endometritis  and  acute  salpingitis,  usually  is  present  in 
chronic  salpingitis,  and  sometimes  is  one  of  the  symptoms  of 
retrodisplacement  of  the  uterus. 

Membranous  dysmenorrhea  is  a  symptom  of  the  curious 
disease  known  as  exfoliative  endometritis,  which  causes  shedding 


DYSMENORRHEA  65 

of  the  endometrium  in  shreds  or  even  as  a  complete  cast  of  the 
uterine  cavity.  It  really  belongs,  therefore,  to  the  type  in 
which  the  cervical  canal  is  normal  in  size  but  too  small  to  permit 
the  passage  of  the  shreds  without  painful  expulsive  effort  on 
the  part  of  the  uterus. 

The  origin  of  spasmodic  dysmenorrhea  may  be  said  to  be 
wholly  problematical.  Many  attempts  have  been  made  to 
prove  its  dependence  upon  some  organic  change  in  the  pelvic 
organs,  more  particularly  in  the  uterus  at  and  about  the  internal 
orifice,  but  none  of  the  arguments  presented  can  be  said  to  have 
passed  beyond  the  stage  of  theoretical  conception.  It  is  present 
in  some  young  girls  and  nulliparous  women  whose  pelvic 
organs  upon  examination  prove  to  be  normal  in  every  respect, 
and  it  is  closely  associated  with  the  general  health  of  the  patient 
and  especially  with  the  tone  of  her  nervous  system.  School 
girls  and  teachers  who  suffer  extremely  from  menstrual 
'' cramps"  during  the  school  year  may  menstruate  with  little 
or  no  pain  during  the  vacation  period.  Examination  made 
during  the  height  of  the  pain  may  show  the  blood  escaping 
from  the  cervix  in  a  steady  stream,  and  the  passage  of  a  probe 
may  be  entirely  unobstructed  although  intensely  painful. 
These  and  many  other  facts,  together  with  the  result  of  various 
forms  of  treatment,  compel  us  to  classify  spasmodic  dysmenor- 
rhea as  a  neurosis,  even  though  further  research  reveals  some 
pathological  change  in  the  uterine  nerves. 

Two  distinct  types  of  pain  are  observed  in  dysmenorrhea,  the 
aching  and  dragging  of  the  congestive  form,  and  the  rhythmic 
cramps  of  all  the  others.  The  aching  and  bearing  down  are 
readily  explained  by  the  increased  pelvic  congestion  which 
precedes  and  accompanies  menstruation,  and  are  merely  an  addi- 
tion to  the  discomfort  of  the  primary  disease.  The  cramp-Hke 
pain  of  obstructive,  membranous,  and  spasmodic  dysmenorrhea 
is  due  to  painful  contractions  of  the  uterus,  and  in  its  rhythmic 
character  it  simulates  the  ''pains"  of  labor.  Usually  it  is 
felt  most  intensely  in  the  hypogastrium,  but  it  may  extend  into 
5 


66  SYMPTOMATOLOGY  AND   DIAGNOSIS 

the  groins  or  down  the  legs,  and  in  a  few  instances  is  located 
wholly  in  the  back. 

In  obstructive  and  membranous  dysmenorrhea  the  pain 
subsides  as  soon  as  the  obstruction  is  overcome  or  the  membrane 
expelled.  In  the  spasmodic  form  it  may  begin  several  hours 
before  menstruation  is  due  and  persist  for  a  day  or  two  after 
the  flow  is  well  estabhshed. 

Two  or  more  forms  may  co-exist,  and  it  is  not  wise  to  base  a 
diagnosis  upon  the  symptoms  alone  except  in  young  girls  and 
unmarried  women  in  whom  a  diagnosis  by  exclusion  sometimes 
can  be  arrived  at  without  examination.  If  no  membrane  is 
present,  this  variety  is  ruled  out,  and  actual  congenital  organic 
obstruction  is  a  curiosity  unless  so  complete  as  to  produce 
absolute  amenorrhea.  Chronic  inflammatory  pelvic  disease 
in  virgins  is  practically  unknown  unless  it  follows  acute  appen- 
dicitis with  pelvic  exudate  or  is  tuberculous  in  origin  and  as- 
sociated with  other  evidences  of  tuberculous  peritonitis,  so  that 
the  spasmodic  type  may  be  presumed  to  exist  unless  evidence 
to  the  contrary  is  quite  plain,  or  the  pain  is  so  uniformly  present 
under  all  circumstances  as  to  lead  to  the  presumption  that  it 
has  a  definite  organic  cause. 

Attention  should  be  called  to  the  uniform  increase  in  men- 
strual pain  which  is  the  common  result  of  too  close  association 
with  the  opposite  sex,  and  the  hidden  factor  of  an  over-ardent 
lover  accounts  for  many  exacerbations  of  a  previously  moderate 
dysmenorrhea. 

Menorrhagia  and  Metrorrhagia. — Profuse  regular  menstrua- 
tion, technically  known  as  menorrhagia,  may  originate  from  a 
general  blood  disorder  such  as  ha^^mophilia,  or,  curiously  enough, 
sometimes  from  anaemia.  Usually  it  is  distinctly  a  pelvic  affair, 
when  it  still  may  be  due  to  some  general  cause  such  as  passive 
congestion  of  the  uterus  from  decompensation  of  a  cardiac 
lesion.  More  frequently,  however,  it  is  due  to  a  purely  local 
lesion  such  as  retroversion,  sub-involution,  uterine  congestion 
secondary  to  acute  inflammatory  processes  in  the  tubes  and 


EXAMINATION  AND   OBJECTIVE   SIGNS  67 

ovaries,  or  acute  endometritis.  That  form  of  chronic  endo- 
metritis which  is  known  cHnically  as  polypoid,  fungoid,  or 
hemorrhagic,  has  as  its  sole  symptom  profuse  menstruation. 
Myomata  of  the  uterus,  unless  distinctly  sub-peritoneal  and 
pedunculated,  usually  cause  menorrhagia  through  their  in- 
fluence on  the  endometrium  as  well  as  from  the  increased  size 
of  the  uterus. 

Patients  at  or  about  the  menopause  may  flow  excessively 
without  any  demonstrable  local  disease,  but  it  should  not  be 
taken  for  granted  that  disease  is  absent  until  a  thorough  ex- 
amination has  proven  it  so. 

Young  girls  at  the  beginning  of  menstrual  Hfe  sometimes  flow 
profusely  until  their  regular  menstrual  habit  has  been  estab- 
Kshed.  Later  in  hfe,  the  quantity  of  blood  lost  and  the  duration 
of  the  periods  are  not  so  important  in  establishing  a  diagnosis 
of  menorrhagia  as  is  a  marked  departure  from  this  previously 
estabhshed  habit. 

Myomata  also  frequently  cause  intermenstrual  hemorrhage, 
technically  known  as  metrorrhagia,  and  they,  together  with 
cervical  polypi  and  mahgnant  disease  of  the  cervix  and  body 
of  the  uterus,  are  its  more  frequent  causes.  Conversely,  this 
symptom  may  be  the  only  one  of  early  mahgnant  disease. 

Finally,  the  association  of  metrorrhagia  with  ectopic  preg- 
nancy, and  the  bleeding  due  to  threatened  abortion  in  early 
normal  pregnancy,  must  both  be  taken  into  account  in  attempt- 
ing to  determine  the  cause  of  irregular  bleeding  from  the  uterus. 

EXAMINATION  AND  OBJECTIVE  SIGNS 

Objective  signs  are  those  indications  of  disease  which  are 
made  evident  to  the  examiner's  senses  through  a  physical  ex- 
amination of  the  patient.  The  methods  of  examination  com- 
prise not  only  those  made  use  of  in  physical  examination 
elsewhere,  such  as  inspection,  palpation,  percussion,  and  aus- 
cultation; but  also  digital  touch  through  the  vagina  and  rectum 


68  SYMPTOMATOLOGY   AND   DIAGNOSIS 

and  bi-manual  examination  through  the  same  avenues.  By 
means  of  the  latter,  organs  otherwise  out  of  reach  may  be 
brought  into  contact  with  the  examiner's  fingers.  In  obscure 
lesions  not  only  may  all  of  these  methods  be  necessary  but  in 
addition  microscopic  examination  of  urethral,  vaginal,  and 
cervical  discharge,  of  section  or  scrapings  of  suspicious  tissue, 
and  examination  of  the  blood.  Chemical  and  microscopic 
examination  of  the  urine  always  is  necessary. 

Both  knowledge  and  tact  are  essential  in  determining  when  a 
gynaecologic  examination  is  required  and  when  it  may  be  omitted, 
and  in  securing  the  necessary  examination  without  embarrass- 
ment either  to  patient  or  examiner.  In  a  general  way  it  is  as 
faulty  to  treat  a  gynaecologic  patient  without  a  pelvic  examina- 
tion as  it  is  to  treat  a  chronic  cough  without  examination  of  the 
chest,  but  there  are  occasions  when  the  experienced  physician 
knows  that  an  examination  is  not  only  unnecessary  but  out  of 
place.  These  are  usually  when  the  patients  are  young  girls 
or  young  unmarried  women  who  have  menstrual  anomalies 
which  are  temporary  in  character,  or  else  have  such  distinctive 
symptoms  that  a  diagnosis  is  possible  on  the  basis  of  the  history 
alone.  When  an  examination  is  considered  advisable,  the 
patient  should  not  be  asked  if  she  will  admit  to  it  but  should  be 
told  that  examination  is  required,  and  asked  only  to  state 
whether  she  is  prepared  for  it  at  present  or  wishes  to  defer  it 
until  some  other  time. 

It  has  been  stated  previously  that  hysteria  may  mimic  pelvic 
disease,  but  it  also  should  be  understood  that  many  other  general 
conditions  produce  symptoms  which  the  patient  refers  to  her 
pelvis,  and  particularly  that  patient  may  have  not  only  pelvic 
disease  but  other  organic  diseases  as  well.  Thus  it  frequently 
happens  that  the  physician  is  in  serious  doubt  as  to  what  lesion 
is  responsible  for  the  discomfort  even  after  a  most  compre- 
hensive diagno.sis.  In  simj)le  uncomplicated  cases,  such  as 
complete  laceration  of  the  perineum,  pelvic  examination  may 
suffice,  but  more  often  the  entire  abdomen  must  be  interrogated, 


ANESTHESIA  FOR  EXAMINATION  69 

the  urine  examined,  the  condition  of  the  heart  and  lungs  as- 
certained, and  the  evidences  of  functional  nervous  disorder 
be  sought  for.  It  is  a  safe  plan  to  go  over  all  the  abdominal 
organs,  the  heart,  and  the  kidneys,  in  every  case  in  which 
a  gynaecologic  examination  is  required. 

The  patient  should  remove  her  corset  and  loosen  all  articles 
of  clothing,  especially  the  waist  bands,  and  an  adjoining  room 
or  screened  corner  of  the  consulting  room  should  be  provided 
for  this  purpose. 

The  lower  bowel  and  bladder  must  be  evacuated  and  if  there 
is  any  doubt  concerning  the  condition  of  the  latter  it  should  be 
emptied  by  catheter  under  aseptic  precautions.  The  latter 
procedure  is  advisable  as  a  routine  practice,  not  only  to  be  as- 
sured that  the  bladder  is  empty,  but  also  to  secure  a  specimen 
of  urine  contaminated  by  vaginal  or  vulvar  discharge. 

Anaesthesia. — Pelvic  and  abdominal  examinations  usually 
can  be  completed  without  the  use  of  an  anaesthetic,  but  oc- 
casionally a  patient  is  seen  whose  sensitiveness  to  pain  is  so 
great  that  muscular  rigidity  interferes  with  satisfactory  palpa- 
tion and  thus  the  administration  of  an  anaesthetic  is  made 
necessary,  as  it  also  is  if  "the  patient  has  a  very  thick  abdominal 
wall  which  demands  a  degree  of  relaxation  it  is  impossible  to 
secure  by  voluntary  effort. 

When  the  administration  of  ether  is  demanded,  it  should  be 
preceded  by  proper  preparation  and  should  be  given  by  a  skilled 
anaesthetist  only. 

Anaesthesia,  however,  is  rarely  required  in  patients  who 
have  chronic  disease,  since  a  second  or  even  third  examination 
usually  will  lead  to  a  satisfactory  diagnosis,  and  the  repetition 
of  examinations  is  preferable  to  the  inconvenience,  discomfort 
and  danger  of  anaesthesia. 

Position. — For  abdominal  examination  the  patient  should 
lie  in  the  dorsal  position  with  the  head  slightly  raised,  while 
examination  "of  the  genitaha  may  be  made  with  the  patient 
either  in  the  Hthotomy  or  Sims's  position,  usually  the  former. 


70 


SYMPTOMATOLOGY   AND   DIAGNOSIS 


An  examining  table  is  a  great  convenience  as  it  permits  of  the 
freer  use  of  the  hands  than  a  couch  or  bed  and  the  position  of 
the  examiner  is  less  strained.     The  patient  should  be  brought 


YiG.  24. — Sims'  or  latero-prone  position. 

well  down  to  the  edge  of  the  table  and  the  feet  supported  by 
stirrups  provided  for  that  purpose.  In  examining  a  patient  at 
her  home  an  ordinary  kitchen  table  may  be  utilized  if  she  is 
not  too  ill  to  be  moved.     If  she  must  be  examined  in  bed  with 


Fig.  25. — The  knee-chest  posture. 

as  little  disturbance  as  possible  il  will  be  found  that  reaching 
the  pelvic  organs  is  facilitated  it'  the  hips  are  elevated  upon  a 
small  pillow. 


METHODS    OF   EXAMINATION  7 1 

The  lateral  position  for  the  detection  of  movable  kidney,  the 
knee-chest  position  in  proctoscopy,  and  the  erect  position  for 
determination  of  the  degree  of  prolapse  of  the  kidney  or  uterus 
are  sometimes  required  and  will  be  mentioned  again  when  those 
subjects  are  under  consideration. 

Extreme  exposure  of  the  patient  never  is  necessary,  and 
those  portions  of  the  body  not  under  direct  observation  should 
be  properly  covered,  but  no  consideration  of  modesty  should 
lead  to  imperfect  exposure  of  such  parts  as  it  is  necessary  to 
see  in  order  to  secure  full  information. 

Instruments. — The  simpler  and  fewer  the  instruments  used 
the  better.  All  office  instruments  should  be  sterihzed  as  more 
than  one  instance  is  on  record  of  infection  through  the  medium 
of  imperfectly  steriHzed-specula  and  sounds.  The  more  the  hands 
displace  instruments  the  better  becomes  the  tactile  sense  of 
the  physician,  and  the  less  often  does  he  find  himself  unable 
to  complete  an  examination  away  from  the  office  or  hospital 
because  some  instrument  is  mislaid  or  forgotten.  A  stetho- 
scope, a  bivalve  vaginal  speculum  of  the  simplest  type,  a  bi- 
valve or  trivalve  rectal  speculum,  a  long  dressing  forceps,  and 
dull  tenaculum  forceps  are  most  frequently  required,  while  the 
Sims's  speculum  or  other  form  of  single-bladed  perineal  re- 
tractor and  the  uterine  sound  are  needed  occasionally.  The 
sound  is  fairly" pregnant  with  danger  and  never  should  be  used 
unless  absolutely  necessary. 

Inspection. — While  it  is  customary  to  combine  inspection 
of  the  abdomen  with  palpation,  percussion,  etc.,  before  the 
genitaha  are  examined,  it  gives  a  better  idea  of  the  scope  of  the 
various  methods  of  examination  if  they  are  discussed  separately. 

Upon  inspection  of  the  abdomen  one  should  note  all  visible 
deviations  from  the  normal.  Changes  in  the  color  of  the  skin 
can  be  observed  and  may  be  only  part  of  a  general  dis- 
coloration as  from  obstructive  jaundice,  or  the  discoloration 
may  be  confined  to  the  abdomen  or  a  localized  portion  of  the 
abdomen.     Prolonged  hot  apphcations  and  bHsters  frequently 


72 


SYMPTOMATOLOGY  AND   DIAGNOSIS 


Fig.  26. — Instruments  for  vaginal  examination,  i,  Bivalve  speculum;  2, 
single-bladed  perineal  retractor;  3,  straight  volsellum  forceps;  4,  curved  tenacu- 
lum forceps;  5,  uterine  dressing  forceps;  6,  uterine  sound. 


INSPECTION  73 

leave  an  area  of  bronzing.  Pregnancy  gives  the  dark  stripe 
up  the  median  line;  and  over-stretching  of  the  skin,  whether 
due  to  pregnancy,  tumor,  or  the  rapid  development  of  fat, 
causes  the  deHcate  pink  and  white  striae  which  later  take  on  a 
scar-like  appearance.  The  white  shiny  look  of  the  oedematous 
skin  over  an  ascitic  abdominal  cavity  also  may  be  observed. 

The  abdominal  contour  should  be  noted.  The  fiat,  flabby 
abdominal  wall  leads  one  to  suspect  visceral  ptosis  and  dis- 
placement of  the  pelvic  organs.  The  regularly  enlarged 
abdomen  at  once  reminds  one  of  pregnancy,  ovarian  cyst,  and 
ascites;  while  irregular  or  nodular  enlargement  leads  one  to 
think  of  fibroma  of  the  uterus,  tuberculous  peritonitis,  or  a 
malignant  growth.  Visible  peristaltic  waves  make  it  necessary 
to  determine  whether  a  point  of  obstruction  is  not  present 
somewhere  in  the  alimentary  canal. 

Inspection  of  the  vulva  reveals  parasites  or  their  larvae, 
the  thickened  corrugated  skin  of  pruritis  vulvae,  the  white 
shiny  pearl-like  skin  of  kraurosis,  and  the  bright  red  of  vulvitis. 
The  blue  or  purple  discoloration  of  pregnancy  may  be  present, 
and  at  a  very  early  date  this  can  be  seen  just  below  the  external 
urethral  orifice.  A  yellow  purulent  discharge  may  be  observed 
exuding  from  the  urethra  in  acute  gonorrhea,  and  a  tiny  red 
spot  at  the  orifice  of  the  duct  of  the  greater  vestibular  gland 
may  confirm  the  suspicion  of  an  old  gonorrhea.  Urethral  car- 
uncle, condylomata,  chancre,  varices  in  the  labia,  the  outlines 
of  a  distended  Bartholinian  gland,  and  epitheliomata,  may  all 
be  seen  and  sometimes  diagnosed  by  inspection  alone. 

The  condition  of  the  hymen,  whether  imperforate,  un- 
ruptured, or  ruptured,  may  be  taken  in  at  a  glance,  and  the 
extent  of  an  injury  from  a  previous  labor  may  be  estimated 
by  the  distance  of  the  anus  from  the  external  urethral  orifice, 
the  gaping  of  the  vulva,  and  the  presence  of  scars  about  the 
vaginal  entrance. 

Inspection  of  the  vagina  and  cervix  is  best  made  by  the  aid 
of  the  bivalve  speculum  which  separates  the  anterior  and  pos- 


74 


SYMPTOMATOLOGY   AND   DIAGNOSIS 


terior  walls  of  the  vagina  and  so  exposes  to  view  its  lateral 
walls,  the  vaginal  fornices,  and  the  cervix.  The  Sims's  or  any 
single-bladed  speculum,  depends  for  its  efficiency  upon  the  fact 
that  if  the  patient  lies  in  the  latero-prone  position  while  the 
perineum  is  retracted,  air  rushes  into  the  vagina  and  distends 
it  so  that  a  more  complete  smoothing  out  of  its  rugae  is  ac- 
complished.    Practically   this  is  rarely  necessary  and   as  an 


/  \ 


Fig.  27. — Relaxed  vag- 
inal outlet.  Owing  to  in- 
jury to  pelvic  diaphragm  the 
vulva  gapes  and  the  anus 
has  dropped  posteriorly. 


Fig.  28. — Intact  vulva 
after  labor.  Hymen  ab- 
sent. Hymeneal  caruncles 
smoothed  out,  but  anus 
and  urethral  orifice  not 
widely  separated. 


assistant  is  required  for  its  use  it  cannot  be  utilized  in  ofhce 
practice  so  readily  as  the  bivalve.  Certain  forms  of  fenestrated 
blades,  and  specula  with  three  or  even  four  blades  occasionally 
are  useful  in  treatment,  but  are  by  no  means  essential  for 
examination. 

The  bivalve  speculum  should  be  warmed,  oiled  with  sterilized 
vaseline  or  other  sterile  lubricant,  and  introduced  with  its 
blades  closed.     Slight  backward  pressure  upon  the  perineum 


PERCUSSION  75 

should  be  made  as  the  tip  is  introduced  in  order  to  avoid  pres- 
sure upon  the  sensitive  urethral  orifice,  and  the  end  of  the 
instrument  should  follow  the  direction  of  the  posterior  vaginal 
wall.  Upon  opening  the  speculum  the  cervix  drops  between 
the  ends  of  the  blades,  or  it  may  be  made  to  do  so  by  a  little 
manipulation.  The  walls  of  the  vagina  may  thus  be  seen  and 
any  abnormalities  of  color,  discharge,  etc.,  be  detected.  The 
appearance  of  the  cervix  should  be  carefully  observed.  Nabo- 
thian  folhcles,  advanced  carcinoma,  polypi,  erosions,  prolapse 
of  the  cervical  mucosa,  hypertrophy  of  the  entire  cervix,  and 
stenosis  of  the  external  os  are  visible.  Laceration  of  the 
cervix  may  be  apparent  at  a  glance,  but  partial  closing  and 
opening  of  the  speculum  is  sometimes  necessary  in  order  to 
differentiate  the  torn  cervix  with  healed  edges  from  a  simple 
hypertrophy. 

Percussion. — Percussion  is  of  value  in  gynaecologic  diagnosis 
in  a  Hmited  number  of  instances,  but  sometimes  its  findings  are 
of  positive  value. 

Normally  the  percussion  note  over  the  entire  anterior  ab- 
dominal wall,  from  the  costal  margin  down,  gives  a  tympanitic 
note  from  gas  in  the  alimentary  tract.  Collections  of  fecal 
matter  in  the  large  intestine  may  give  a  dull  note,  but  if  the 
bowel  has  been  emptied  as  directed  tympany  is  everywhere 
present,  although  the  pitch  of  the  note  varies  over  the  different 
hollow  viscera.  Distension  of  the  stomach  by  air  introduced 
through  a  stomach  tube,  or  by  carbon  dioxide  through  the  use  of 
a  SeidHtz  pow^der  the  two  portions  of  which  have  been  dissolved 
and  drunk  separately,  enables  one  to  outHne  the  stomach  by 
this  difference  in  the  percussion  note.  Likewise  the  location 
of  the  colon  and  its  relation  to  any  abnormal  mass  in  the 
abdomen  can  be  made  out  by  colonic  inflation  and  observation 
of  the  relation  of  the  distended  tympanitic  colon  to  the  mass. 
This  inflation  is  readily  accompKshed  with  an  atomizer  bulb 
attached  to  the  ordinary  rectal  nozzle.  A  distended  gall- 
bladder lies  in  front  of  the  inflated  colon  and  an  enlarged  or 


76 


SYMPTOMATOLOGY  AND   DIAGNOSIS 


movable  right  kidney  is  behind  it;  an  enlarged  or  prolapsed 
spleen  is  in  front  of  the  colon  and  a  displaced  left  kidney  behind 
it.  Areas  of  dullness  or  flatness  in  the  upper  abdomen  may  be 
produced  by  an  enlarged  liver  or  spleen,  by  new  growths,  by 


OALLBLADDffi 
KIDNEY  


^LEEN 


JQDNEr 


Fig.  29. — Diagram  illustraling  "A  displaced  right  kidney  lies  behind  dis- 
tended colon,  the  gall-bladder  in  front  of  it.  An  enlarged  or  displaced  left 
kidney  lies  behind  the  colon,  the  spleen  in  front  of  it." 


retained  stomach  contents,  or  by  exudate  about  infected  viscera. 
Perforated  viscera,  and  appendicitis  either  with  or  without 
perforation,  may  result  in  large  abscess  cavities,  the  exudate 
about  which  gives  dullness,  while  over  the  cavity  itself  a  tym- 
panitic note  is  heard  which  is  due  to  gas  formation  from  the 


AUSCULTATION  77 

activities  of  the  colon  bacillus.  Tuberculous  peritonitis  with 
exudate  may  give  rise  to  flatness  over  localized  collections  of 
fluid  anywhere  in  the  abdominal  cavity.  A  dull  or  flat  note 
over  the  pelvic  cavity  sometimes  is  found  in  recently  ruptured 
ectopic  pregnancy  with  profuse  hemorrhage,  and  always  is 
found  directly  over  a  pregnant  uterus  or  a  tumor  of  the  uterus 
or  ovary.  Change  in  the  location  of  a  flat  area,  due  to  free 
fluid  in  the  abdominal  cavity,  when  the  patient  is  turned  from 
side  to  side  is  characteristic  of  ascites  and  assists  in  distin- 
guishing it  from  pregnancy,  a  new  growth,  and  walled-off  effu- 
sion such  as  is  found  in  tuberculous  peritonitis. 

Auscultation. — Auscultation  over  the  normal  abdomen  reveals 
the  gurghng  of  gas  and  fluid  in  the  stomach  and  intestine  which 
probably  is  due  to  peristalsis.  Its  entire  absence  is  indicative 
of  intestinal  paresis  and  may  mean  general  peritonitis.  Im- 
mediately after  an  abdominal  operation  there  may  be  absence 
of  these  peristaltic  sounds  because  of  traumatic  paresis  but 
this  passes  away  after  a  few  hours.  Under  either  of  these  con- 
ditions the  respiratory  and  cardiac  sounds  are  likely  to  be  plainly 
perceptible. 

Violent  peristaltic  sounds  are  heard  during  the  early  stages 
of  organic  intestinal  obstruction  and  correspond  in  time  to 
rhythmic  attacks  of  pain.  A  distinct  bruit,  synchronous  with 
the  patient's  pulse,  may  be  distinguished  over  the  large  vessels 
of  the  abdomen  if  sufflcient  pressure  is  made  with  the  stetho- 
scope, but  not  otherwise. 

Auscultation  over  a  tumor  which  has  its  origin  in  the  pelvis 
and  rises  into  the  abdominal  cavity  may  serve  to  distinguish 
the  pregnant  uterus  from  a  new  growth.  The  so-called  uter- 
ine bruit  of  pregnancy  is  heard  over  no  other  abdominal  en- 
largement save  an  occasional  myoma.  This  bruit  is  syn- 
chronous with  the  patient's  pulse  and  is  most  distinct  just 
external  to  the  uterine  fundus  on  either  side.  Repeated 
observation  has  convinced  the  author  that  the  origin  of  this 
bruit  is  not  in  the  uterus  but  in  the  utero-ovarian  artery  just 


78  SYMPTOMATOLOGY  AND  DIAGNOSIS 

below  the  uterine  tube.  Foetal  heart  sounds  may  be  heard 
over  a  similar  enlargement  if  pregnancy  beyond  seven  months 
is  present  and  the  foetus  is  living. 

Auscultation  is  thus  chiefly  of  value  in  differentiating  ad- 
vanced pregnancy  from  other  sources  of  enlargement  of  the 
abdomen,  and  it  assists  in  the  diagnosis  of  general  peritonitis 
and  intestinal  obstruction. 

Palpation. — It  is  through  the  tactile  sense  of  the  examiner's 
fingers  that  the  principal  objective  signs  of  disease  of  the 
abdominal  and  pelvic  viscera  are  discovered,  and  this  method 
is  known  as  palpation. 

Abdominal  palpation  is  performed  with  one  or  both  hands, 
and  by  it  an  effort  is  made  to  ascertain  the  presence  or  absence 
of  rigidity  of  the  abdominal  walls,  elicit  either  superficial  or 
deep  tenderness,  outline  the  organs  in  their  normal  position, 
and  discern  the  size,  shape,  consistency,  etc.,  of  displaced  or 
diseased  viscera.  Palpation  through  the  medium  of  one  or 
more  fingers  in  the  vagina  or  rectum  is  known  respectively  as 
digital  vaginal  or  digital  rectal  examination.  Palpation  with 
the  finger  or  fingers  of  one  hand  in  the  vagina  or  rectum,  while 
the  other  hand  makes  counter  pressure  upon  the  abdomen  in 
such  manner  as  to  bring  the  pelvic  viscera  between  the  hands 
thus  occupied,  is  known  as  bi-manual  vaginal  or  bi-manual 
rectal  examination. 

The  normal  size,  shape,  mobility,  and  consistency  of  all  the 
palpable  organs  must  be  familiar  before  deviation  from  the 
normal  can  be  appreciated,  and  for  this  reason,  if  for  no  other, 
the  occasion  should  be  grasped  to  make  a  complete  examina- 
tion at  every  possible  opportunity. 

Abdominal  palpation  should  be  made  with  the  hands  warm 
and  placed  flat,  and  at  the  beginning  of  the  examination  it 
should  be  very  gentle.  If  a  given  abdominal  area  is  known  to 
be  tender,  it  should  be  avoided  during  the  early  part  of  the 
examination,  and  an  effort  should  be  made  to  ascertain  the 
general  sensitiveness  of  the  skin  covering  the  abdominal  wall 


PALPATION 


79 


and  the  voluntary  resistance  of  the  muscles  to  pressure,  leav- 
ing known  diseased  areas  until  this  information  is  obtained. 
As  the  patient  gains  confidence  and  learns  that  she  will  not  be 


Fig.  30, — Abdominal  palpation.     Proper  method,  hand  flat  on  abdominal  wall. 


Fig.  31. — Abdominal  palpation.     Improper  method,   fingers  applied  end  on. 

made  to  suffer  unnecessary  pain,  more  pressure  can  be  made, 
and  it  often  happens  that  a  stout  rigid  belly  wall  will  become 
soft  and  relaxed  as  it  becomes  accustomed  to  the  necessary 
manipulations.     The   advantage   of   distracting   the  patient's 


8o  SYMPTOMATOLOGY   AND   DIAGNOSIS 

attention  and  securing  easy  tranquil  respiration  should  not  be 
overlooked. 

By  palpation  of  the  organs  of  the  upper  abdomen  but  little 
can  be  made  out  when  they  are  normal.  On  deep  inspiration 
the  edge  of  the  liver  may  be  felt  and  the  lower  pole  of  the 
right  kidney  palpated  between  the  hands.  The  left  kidney 
rarely  can  be  found  unless  abnormally  mobile.  If  the  ab- 
dominal wall  is  very  thin  and  relaxed,  the  pylorus  can  some- 
times be  felt  undergoing  alternate  contraction  and  relaxation, 
and  the  empty  coecum  can  be  rolled  under  the  fingers. 

That  the  normal  appendix  ever  is  palpated  is  doubtful,  al- 
though some  skillful  examiners  claim  to  be  able  to  perform 
this  feat. 

Localized  superficial  tenderness  may  be  due  to  underlying 
disease  as  pointed  out  by  Head,  and  a  careful  perusal  of  his 
article  is  well  worth  the  time  required  as  it  emphasizes  the 
relation  between  disease  of  the  various  viscera  and  the  corre- 
sponding sensitive  skin  areas.  Deep  tenderness  usually  means 
disease  of  the  underlying  organ  upon  which  pressure  is  made. 

By  palpation  of  the  abdomen  above  the  umbilicus  one  notes 
displacement  or  enlargement  of  the  kidney,  spleen,  or  liver, 
distension  of  the  gall-bladder,  new  growths  in  the  abdominal 
wall,  in  the  organs  in  the  peritoneal  cavity,  or  in  the  retro- 
peritoneal lymph  glands,  and  the  exudate  due  to  inflammation 
about  infected  areas  which  involve  the  peritoneum. 

Palpation  of  the  abdomen  below  the  umbilicus  may  reveal 
the  same  abnormalities,  and  in  addition  enlarged  organs,  tumors, 
or  exudate  which  rise  into  the  abdomen. 

Assistance  in  determining  the  normal  location  of  a  displaced 
organ  or  the  attachment  of  a  new  growth  can  be  obtained  by 
discovering  and  palpating  its  pedicle  and  replacing  the  organ 
in  that  direction  from  which  the  pedicle  proceeds.  Adhesions 
to  surrounding  structures  may  prevent  such  displacement, 
when  the  size,  shape,  and  consistency  of  any  normal  organ  which 
might  occupy  this  locality  should  be  given  consideration,  to- 


VAGINAL  EXAMINATION 


8l 


gether  with  all  the  possible  disease  processes  which  could  pro- 
duce conditions  such  as  are  found  in  the  individual  case. 

Digital  Vaginal  Examination. — As  remarked  before,  this  is  a 
method  of  palpation  with  the  finger  or  fingers  in  the  vagina. 


Fig.  32. — Method  of  performing  bimanual  vaginal  examination. 


While  it  is  habitual  with  some  to  use  two  fingers  of  the  same 
hand,  it  will  in  the  long  run  be  found  most  satisfactory  to  use 
6 


82  SYMPTOMATOLOGY  AND   DIAGNOSIS 

the  forefinger  of  each  hand,  the  right  for  the  right  side  of  the 
pelvis  and  the  left  for  the  left. 

The  labia  should  be  separated  and  the  finger  introduced  and 
turned  with  its  palmar  surface  laterally  to  test  the  resistance 
of  the  pelvic  outlet.  Normally,  the  fibers  of  the  levator  ani 
muscle  on  either  side  can  be  felt  like  one-half  of  a  sling  support- 
ing the  vagina  and  rectum  and  offering  marked  resistance  to 
their  backward  displacement.  Any  laceration  into  the  rectum 
will  have  been  discovered  by  previous  inspection,  and  under 
these  circumstances  the  levator  will  be  felt  intact,  as  its  fibers 
pass  lateral  to  the  vagina  to  be  attached  behind  the  posterior 
rectal  wall.  Injuries  which  interfere  with  the  function  of  the 
pelvic  floor  as  a  diaphragm  will  be  indicated  by  the  absence  of 
this  sling  of  levator  on  one  or  both  sides.  The  distance  of  the 
cervix  from  the  vaginal  orifice,  and  the  direction  in  which  it 
points,  should  be  ascertained.  Injuries  to  the  cervix  are  pal- 
pable, and  nodules  due  to  Nabothian  follicles,  cervical  fibroids, 
or  carcinoma,  can  be  felt. 

The  finger  in  the  vagina,  unaided  by  pressure  from  above, 
rarely  is  able  to  appreciate  changes  in  the  organs  superior  to 
the  vaginal  fornices  except  in  the  case  of  large  tumors  or  pelvic 
exudate  which  of  themselves  provide  sufficient  counterpressure. 

Bi-manual  Vaginal  Examination. — It  is  upon  this  method  of 
palpation  that  recognition  of  the  greater  number  of  diseases  of 
the  supra-vaginal  portion  of  the  pelvic  organs  depends.  The 
finger  is  introduced  into  the  vagina  as  in  digital  examination 
and  the  other  hand  placed  flat  upon  the  anterior  abdominal  wall, 
its  purpose  being  to  fix  the  pelvic  structures  and  enable  the 
vaginal  finger  to  appreciate  their  size,  shape,  consistency,  and 
attachments.  The  pressure  required  of  the  hand  on  the  abdo- 
men varies  with  the  degree  of  resistance  ofi"ered  by  the  ab- 
dominal wall,  and  it  always  operates  to  greater  advantage  if 
the  patient  ran  be  persuaded  to  relax  her  abdominal  muscles 
completely.  By  some  individuals  this  can  be  done  voluntarily, 
while  others  resist  in  spite  of  all  efforts  to  the  contrary  unless 


EXAMINATION  PER  RECTUM  83 

their  attention  can  be  diverted  from  the  examination  which 
they  are  undergoing.  By  using  gentle  steady  pressure  and 
being  careful  to  give  no  more  pain  than  is  absolutely  necessary, 
a  satisfactory  exploration  of  all  the  pelvic  structures  usually  can 
be  accomplished,  but  an  extremely  nervous  patient,  or  disease 
which  produces  exquisite  sensitiveness,  will  defeat  the  most 
careful  examiner.  If  under  these  circumstances  the  necessity 
exists  for  an  immediate  diagnosis,  an  anaesthetic  is  indicated. 

Ordinarily  the  uterus  can  be  outlined,  and  its  size,  shape, 
consistency,  and  location  determined.  The  normal  ovaries  are 
palpable,  and  through  a  thin,  flaccid  abdominal  wall  it  is  possible 
to  palpate  the  utero-ovarian  ligaments,  uterine  tubes,  and  the 
round  ligaments  at  their  uterine  extremities.  A  highly  edu- 
cated touch  may  trace  the  normal  ureters  from  the  base  of  the 
bladder  to  their  entrance  into  the  broad  ligaments,  and  dis- 
tinctly enlarged  inflamed  ureters  are  plainly  perceptible. 
Deviations  from  the  normal  in  size,  form,  consistency,  and 
location,  of  the  uterus,  tubes,  and  ovaries  are  determined  by 
bi-manual  examination,  and  peritoneal  exudate  in  the  pelvic 
cavity,  or  the  deposit  of  inflammatory  material  in  the  cellular 
tissue  around  the  cervix  and  in  the  broad  ligaments,  can  be 
felt. 

Digital  and  Bi-manual  Rectal  Examination. — By  digital 
examination  per  rectum  one  can  feel  the  normal  cervix  and 
sacro-uterine  ligaments.  Bi-manually  it  is  possible  to  palpate 
the  entire  uterus,  and  it  is  advisable  to  use  this  method  in 
examining  virgins  because  it  gives  less  pain  than  vaginal 
examination  and  involves  no  risk  of  injury  to  the  hymen. 

Carcinomata,  and  stricture  of  the  rectum  following  other 
ulcerative  processes  can  be  palpated  with  one  finger,  and  the 
grosser  abnormalities  of  the  female  genitalia  are  easily  dis- 
covered through  bi-manual  rectal  examination.  The  rectum 
can  be  inflated  by  placing  the  patient  in  the  knee-chest  posture 
and  opening  the  anus  with  a  small  speculum,  when,  upon  re- 
turning the  patient  into  the  dorsal  position  and  practising  bi- 


84  SYMPTOMATOLOGY  AND   DIAGNOSIS 

manual  rectal  palpation  the  pelvic  structures  will  feel  as 
though  skeletonized  as  pointed  out  by  Howard  Kelly.  Nearly 
or  quite  as  accurate  an  idea  of  the  condition  of  the  pelvic  organs 
can  be  ascertained  by  this  method  as  by  vaginal  examination. 

Microscopic  Examination. — Microscopic  examination  of  the 
discharge  from  the  female  genitalia  is  principally  of  use  in  the 
diagnosis  of  gonorrhea.  While  the  absence  of  gonococci  from 
a  given  specimen  proves  nothing,  their  presence  is  positive  evi- 
dence of  gonorrhea.  Gonococci  most  frequently  are  found  in 
the  discharge  from  the  urethra,  para-urethral  ducts,  Bartho- 
hnian  ducts,  and  the  cervix. 

Other  micro-organisms  such  as  streptococci,  staphylococci, 
and  the  bacillus  coli  are  often  found,  but  none  are  of  diagnostic 
importance  unless  there  are  clinical  evidences  of  infection,  as 
they  may  be  present  about  the  genitaHa  by  accident.  The 
vaginal  bacillus  is  normal  to  the  vagina  and  the  smegma  bacillus 
to  the  surfaces  about  the  urethra  and  clitoris.  The  latter 
organism  sometimes  contaminates  specimens  of  urine  and  is 
mistaken  for  the  bacillus  of  tuberculosis  which  it  closely 
resembles. 

Sections  of  tissue  removed  from  the  genital  organs  have  the 
same  pathological  and  diagnostic  significance  as  from  other 
parts  of  the  body,  and  scrapings  from  the  uterus  if  examined 
systematically  reveal  unexpected,  or  at  least  undiagnosed, 
malignancy  sufficiently  often  to  justify  such  examination  as  a 
routine  measure.  A  diagnosis  based  upon  the  microscopic 
examination  of  scrapings  never  should  be  made,  however,  unless 
the  examination  has  been  performed  by  an  expert  pathologist; 
neither  should  a  negative  pathologic  report  be  accepted  as 
conclusive,  as  it  is  impossible  to  remove  the  entire  endometrium 
with  the  curette.  Routine  microscopic  examination  should  be 
made  of  tissue  removed  from  the  cervix  during  operations  for 
the  repair  of  laceration,  erosion,  or  hypertrophy,  as  malignancy 
may  be  detected  in  this  manner  sufficiently  early  to  enable  a 
cure  to  be  effected  by  radical  operation. 


I  EXAMINATION  OF  THE  BLOOD  85 

A  blood  examination  for  the  estimation  of  haemoglobin,  and 
a  count  of  both  red  and  white  cells  should  be  a  routine  practice 
upon  patients  who  may  be  obliged  to  submit  to  an  operation. 
A  very  low  percentage  of  haemoglobin,  especially  if  due  to  long- 
continued  or  repeated  hemorrhages,  renders  a  patient  a  poor 
subject  for  a  serious  operation,  and  the  detection  of  one  of  the 
primary  anaemias  would  compel  one  to  forego  operation  unless 
it  were  a  positive  necessity.  While  the  leucocyte  count  is  not 
depended  upon  to  the  exclusion  of  clinical  evidence,  it  is  one 
factor  of  value,  not  only  in  establishing  a  diagnosis  but  also  in 
assisting  in  the  determination  of  the  treatment  to  be  pursued. 
As  a  very  general  statement  one  may  say  that  leucocytosis  in- 
creases in  proportion  to  the  severity  of  the  infection  and 
the  resistance  offered  unless  the  infection  is  so  severe  as  to 
overcome  the  patient's  resistance  completely,  in  which  event 
the  leucocyte  count  may  be  normal  or  sub-normal. 

Certain  operative  procedures,  like  salpingectomy  for  gonor- 
rheal salpingitis,  are  best  performed  after  the  infection  has  be- 
come quiescent,  and  a  constant  leucocytosis  would  make  one 
hesitate  to  operate  so  long  as  it  continued.  Well  walled- 
off  abscesses,  even  when  they  contain  virulent  micro-organisms, 
often  give  rise  to  no  leucocytosis,  so  that  absolute  dependence 
cannot  be  placed  upon  this  sign,  but  it  will  always  carry  a 
certain  amount  of  weight  when  taken  in  connection  with  the 
other  signs  and  symptoms  presented. 

The  latest  observations  show  that  more  dependence  is  to  be 
placed  upon  the  findings  of  a  differential  leucocyte  count  than 
upon  the  absolute  increase  in  white  cells  and  that  increase  in 
numbers  is  to  be  regarded  as  an  index  to  the  resistance  of  the 
patient,  while  a  relative  increase  in  the  polymorphonuclear 
leucocytes  bears  more  relation  to  the  gravity  of  the  infection. 
The  polynuclear  cells  normally  comprise  from  60-70  per^  cent, 
of  the  total  number  of  white  cells,  and  if  this  proportionals  in- 
creased to  above  85  or  90  per  cent.,^with  a  moderate  general 
leucocytosis,  it  indicates  a  distinctly  graver  condition  than  does 


86  SYMPTOMATOLOGY   AND   DIAGNOSIS 

a  marked  increase  in  the  total  number  if  the  percentage  of 
polynuclear  cells  remains  relatively  low. 

Attempts  have  been  made  to  establish  certain  definite  rules 
for  determining  the  gravity  of  an  infection  by  the  relative 
proportion  of  the  various  forms  of  leucocytes  present,  but  aside 
from  being  cumbersome  they  have  not  proven  accurate  enough 
to  justify  their  adoption.  At  the  present  time,  laboratory  ex- 
aminations of  the  blood  in  pelvic  infections  are  to  be  accepted 
as  only  one  link  in  the  chain  of  evidence  of  which  the  clinical 
perception  of  the  examiner  still  forms  the  greater  part. 

Examination  of  the  Urine. — Chemic  and  microscopic  ex- 
amination of  the  urine  should  be  a  routine  procedure  in  gynae- 
cology. While  it  may  throw  no  light  whatever  upon  the  gynae- 
cologic  diagnosis  of  an  individual  case,  a  determination  of  the 
proper  treatment  to  be  pursued  often  is  contingent  upon  a 
knowledge  of  the  urinary  condition  present.  In  addition,  the 
urinary  findings  frequently  clear  up  the  diagnosis  of  an  obscure 
case  in  which  the  subjective  symptoms  of  gynaecologic  disease 
are  present  but  examination  of  the  pelvic  organs  reveals  no 
abnormality,  and  in  operative  cases  the  selection  of  the  anaes- 
thetic is  at  times  wholly  dependent  upon  the  urinary  findings. 

The  total  quantity  of  urine  in  24  hours  should  be  ascertained, 
but  a  catheterized  specimen  should  be  utilized  for  routine 
examination  since  contamination  from  vaginal  discharges, 
either  leucorrheal  or  menstrual,  is  so  frequent  as  to  lead  to  the 
apprehension  of  a  disease  of  the  urinary  organs  when  it  does  not 
exist. 

Laboratory  diagnosis  formulated  upon  examination  of  the 
urine  is  upon  a  far  better  basis  than  a  diagnosis  based  upon 
blood  examination  as  the  problems  are  not  only  simpler  but 
better  worked  out.  The  interpretation  of  urinary  findings, 
however,  needs  the  same  clinical  intuition  that  is  of  value  else- 
where, and  there  are  but  few  diseases  in  which  the  urinary 
findings  are  positively  pathognomonic.  Diabetes,  the  various 
forms  of  nephritis,  and  infections  and  tuberculosis  of  the  urinary 


EXAMINATION  OF  THE  BLADDER  87 

tract  are  the  only  disorders  which  can  be  definitely  predicated 
upon  the  urinary  findings  alone. 

It  should  be  noted  that  in  acute  febrile  disease  albumen  and 
hyaline  casts  do  not  necessarily  mean  nephritis,  that  blood 
and  pus  may  come  from  any  portion  of  the  urinary  tract,  and 
that  only  the  most  expert  are  able  to  distinguish  kidney  epi- 
thelium from  that  of  the  ureter  and  deeper  layers  of  the  bladder, 
while  the.jexact  significance  of  bacilli  of  the  colon  group,  with- 
out pus,  is  not  understood. 

Examination  of  the  Bladder. — Examination  of  the  inte- 
rior of  the  bladder  and  securing  of  urine  from  the  kidneys  sepa- 
rately is  easily  accomplished  in  the  female.  The  technique  of 
cystoscopy  should  be  acquired  by  any  practitioner  who  expects 
to  treat  pelvic  disease  either  as  a  specialty  or  a  part  of  general 
medicine  and  surgery. 

^  While  the  complicated  and  troublesome  instruments  necessary 
for  male  cystoscopy  give  equally  good  results  in  the  female 
bladder,  they  are  not  required,  as  the  simpler  instruments  and 
a  very  ordinary  amount  of  dexterity  and  experience  give 
satisfactory  information  in  the  female. 

The  interior  of  tke  female  bladder  may  be  inspected  through 
the  Kelly  cystoscope  by  the  aid  of  reflected  Kght,  or  the  short, 
electric-lighted,  but  direct- vision  cystoscope  may  be  used  without 
the  intervention  of  mirrors  and  lenses. 

Before  using  either  method  the  vulva  should  be  cleansed,  the 
urethra  thoroughly  cocainized,  and  preparation  made  to  con- 
duct the  entire  examination  in  an  aseptic  manner.  For  this 
reason  cystoscopy  is  performed  more  satisfactorily  in  the 
hospital  than  in  the  oflice,  although  there  is  no  reason  why  it 
should  not  take  its  place  as  a  routine  office  procedure  if  the 
proper  equipment  is  at  hand. 

Any  method  of  performing  cystoscopy  demands  distension 
of  the  bladder  in  order  that  the  whole  of  its  interior  may  be 
inspected,  and  also  that  the  bladder  be  not  burned  if  electrically 
lighted  instruments  are  used. 


88 


SYMPTOMATOLOGY  AND   DIAGNOSIS 


Fig.  S3- — Instruments  for  examination  of  the  bladder,  i,  Kelly  cystoscope 
with  obturator  in  place;  2,  Kelly  cystoscope;  3,  obturator;  4,  urethral  calibrator 
and  dilator;  5,  direct  vision,  electric  lighted,  air  dilating,  ureter  catheterizing, 
female  cystoscope;  6,  obturator  for  same;  7,  ocular  window  for  same;  8,  ureteral 
catheter;  9,  Harris  segregator.     Split  catheter  partially  open. 


CYSTOSCOPY  89 

In  using  the  Kelly  method  of  inspection  through  a  short 
endoscope,  the  bladder  is  automatically  inflated  by  the  aid  of 
the  knee-chest  posture  after  all  restraining  bands  have  been 
removed  from  the  waist  and  anterior  abdominal  wall.  In  this 
position  the  viscera  gravitate  toward  the  thorax,  and  relaxation 
of  the  anterior  abdominal  wall  renders  intra-abdominal  pres- 
sure a  negative  instead  of  a  positive  factor.  Thus  when  the 
urethra  is  opened  air  rushes  into  the  bladder  until  it  is  thor- 
oughly distended. 

In  all  other  methods  either  air  or  some  watery  solution  is 
injected  into  the  bladder,  there  being  little  choice  between 
methods  and  instruments  for  this  purpose,  one  examiner  using 
air  and  another  water  as  a  matter  of  habit  and  experience.  The 
air-dilating  instruments  possess  some  advantage  when  there 
is  much  bleeding  or  suppuration  as  the  transparency  of  the 
dilating  medium  is  not  interfered  with  as  it  is  when  aqueous 
solutions  are  used. 

Technique  with  Kelly  Instruments.^ — The  instruments  re- 
quired are  a  head  mirror  and  a  movable  source  of  artificial 
light  or  an  electrically  lighted  head  mirror,  a  calibrator  and 
dilator  combined,  endoscopic  tubes  of  three  sizes  with  ob- 
turators, a  catheter  and  "sucker.'^  If  ureteral  work  is  con- 
templated a  ureteral  sound  and  ureteral  catheters  should  be  at 
hand. 

With  the  patient  in  the  dorsal  position,  the  urethra  is  anaes- 
thetized by  inserting  into  it  a  small  swab  of  cotton  saturated 
with  a  4  or  5  per  cent,  cocaine  solution.  Usually  five  minutes 
will  suffice  for  this  to  be  effected.  Its  caHber  is  then  measured 
with  the  calibrator  and  if  not  sufiiciently  large  it  is  dilated  to 
the  required  size.  The  bladder  is  then  emptied  with  the 
catheter,  and  this  specimen  is  saved  for  examination  and 
comparison  with  the  urines  obtained  by  ureteral  catheterization 
if  the  latter  is  contemplated.  The  patient  is  then  placed  in 
tiie  knee-chest  posture  and  the  endoscope  introduced  with  the 
obturator  in  place.     On  withdrawal  of  the  obturator,  air  fills  the 


90  SYMPTOMATOLOGY   AND   DIAGNOSIS 

bladder  whose  walls  can  then  be  viewed  through  the  tube.  The 
trigone  and  ureteral  orifices  should  be  inspected  first.  These 
are  most  readily  found  by  slowly  withdrawing  the  endoscope 
until  the  internal  urethral  orifice  appears,  then  carefully  push- 
ing it  back  into  the  bladder  a  distance  of  i  cm.  The  inter- 
ureteric  ligament  is  usually  visible  at  its  middle,  and  by 
tracing  it  either  to  the  right  or  left  the  corresponding  ure- 
teral orifice  appears,  sometimes  as  a  slit,  at  others  as  a  tiny 
dimple  from  which  the  urine  is  expelled  in  jets. 

Sometimes  it  is  difficult  to  bring  the  trigone  into  the  field 
owing  to  an  extreme  distension  of  the  bladder  which  crowds  its 
base  too  far  posteriorly,  thus  making  it  necessary  to  lower  the 
outer  end  of  the  tube  until  the  examiner's  head  is  between  the 
patient's  thighs.  This  may  be  overcome,  as  Kelly  has  pointed 
out,  by  opening  the  vagina  which  then  balloons  up  sufficiently 
to  force  the  base  of  the  bladder  into  its  normal  position. 

If  the  ureteral  orifices  are  not  readily  seen  they  may  be  found 
by  careful  use  of  the  ureteral  sound  which  searches  for  them 
at  the  ends  of  the  inter-ureteric  ligament. 

It  is  impossible  either  to  describe  or  picture  the  exact  color 
of  the  normal  mucosa  of  various  portions  of  the  bladder  wall 
and  this  is  learned  only  by  experience,  but  a  few  examinations 
of  the  normal  bladder  enables  one  quickly  to  detect  departures 
from  health.  Pus,  abrasions,  ulcers,  and  new  growths  arc 
appreciated  even  by  a  novice. 

After  the  completion  of  the  examination  the  patient  should 
resume  the  lithotomy  position,  and  the  catheter  again  should  be 
passed  in  order  to  empty  the  bladder  of  its  contained  air  as  the 
latter  is  somewhat  irritating  and  gives  rise  to  uncomfortable 
burning  and  tenesmus  if  long  retained. 

For  purposes  of  diagnosis  this  method  still  remains  the  easiest 
providing  the  examiner  is  skilled  in  the  use  of  the  head  mirror. 

Technique  with  Electrically  Lighted  Instruments. — As 
has  been  stated  above  the  use  of  electrically  lighted  instru- 
ments necessitates  either  air  or  lluid  as  a  dilating  medium, 


CYSTOSCOPY  91 

and  for  the  latter  a  watery  boric  solution  is  found  most  satis- 
factory. Equally  good  results  may  be  obtained  with  either, 
and  preference  is  likely  to  be  given  to  the  one  which  the  ex- 
aminer first  learned.  A  resistance  coil  must  be  thrown  into  the 
electric  circuit  if  the  ordinary  lighting  current  is  used,  and  this 
is  furnished  by  cystoscope  makers  who  must  be  informed 
regarding  the  strength  of  the  current  as  well  as  its  character. 
The  manufacturers  also  supply  portable  dry  cell  batteries  which 
make  one  independent  of  lighting  currents  and  their  vagaries. 
If  the  lighting  current  is  used,  the  table,  stool,  and  examiner 
should  be  insulated  from  the  floor  of  the  room  by  the  use  of 
rubber  matting  in  order  to  prevent  short-circuiting  and  ground- 
ing, which  give  annoying  and  sometimes  painful  shocks. 

After  cocainizing  the  urethra,  dilating  if  necessary,  and 
evacuating  the  bladder,  the  plan  of  procedure  varies  somewhat 
according  to  the  instruments  to  be  used.  If  an  air-dilating 
instrument,  it  is  slipped  into  the  bladder  without  previous 
inflation.  The  obturator  is  withdrawn,  the  window  on  the 
ocular  end  of  the  instrument  attached,  an  atomizer  bulb  shpped 
into  place,  and  air  pumped  in  until  the  patient  is  conscious  of  a 
feeling  of  distension.  The  light  is  now  turned  on  and  observa- 
tion of  the  bladder  wall  made. 

The  inspection  window  should  be  kept  in  hot  sterile  water 
when  not  in  use  to  prevent  immediate  steaming  and  obscuring 
of  the  field.  If  air  escapes  through  the  ureteral  catheter  open- 
ings, it  may  be  replaced  by  gently  squeezing  the  bulb.  With 
this  instrument  care  must  be  taken  to  turn  off  the  light  before 
allowing  the  bladder  to  collapse  or  it  is  certain  to  be  burned. 
The  same  distension  of  the  bladder  can  be  obtained  by  placing 
the  patient  in  the  knee-chest  posture,  as  in  using  the  Kelly 
instruments,  and  no  inspection  window  is  then  necessary. 

If  a  fluid  medium  is  to  be  used,  the  bladder  is  filled  to  the 
extent  of  6  or  8  ounces  before  the  introduction  of  the  cystoscope, 
but  some  of  this  is  lost  during  manipulations  and  must  be 
replaced  after  the  instrument  is  in  situ.     One  advantage  of  the 


92  SYMPTOMATOLOGY  AND   DIAGNOSIS 

latter  instrument  lies  in  the  fact  that  observations  can  be  made 
continuously  until  the  work  is  finished,  while  it  is  rendered 
intermittent  by  steaming  of  the  window  if  an  air-dilating 
cystoscope  is  employed. 

It  should  be  remembered  that  with  any  of  the  methods  de- 
scribed the  picture  shown  is  not  magnified  but  is  a  direct  plain 
view  of  the  structures  under  observation.  With  a  Httle  practice 
the  ureters  may  be  catheterized  without  difficulty,  but  the 
danger  of  carrying  infection  as  well  as  the  confusion  caused 
by  bleeding  from  trauma  to  the  ureter,  has  led  the  author  to 
resort  to  segregation  as  the  routine  procedure  in  women. 
There  are  patients  with  symptoms  of  ureteral  calculus,  or  ure- 
teral stricture,  or  who  have  certain  kidney  lesions  which  neces- 
sitate the  use  of  the  ureteral  catheter,  but  in  women  this 
instrument  is  unnecessary  merely  as  a  means  of  obtaining  urine 
from  the  kidneys  separately,  since  the  elasticity  of  the  base  of 
the  bladder  readily  permits  the  formation  of  a  water  shed  by  the 
vaginal  lever  of  the  segregator.  Even  in  women,  however,  the 
results  obtained  may  be  misleading  if  there  is  much  cystitis 
or  local  areas  of  ulceration,  and  these  should  be  ruled  out  by 
inspection  before  the  segregator  is  used. 

The  Harris  Segregator. — This  instrument  works  very  satis- 
factorily, and  although  others  are  on  the  market  which  are  said 
to  be  more  accurate,  the  simplicity  and  perfect  sterility  of  the 
Harris  instrument  gives  it  a  wide  field  of  usefulness. 

With  the  patient  in  the  Hthotomy  position  the  urethra  is 
cocainized  and  the  bladder  evacuated.  The  instrument  is  in- 
troduced like  a  stiff  catheter  and  the  two  halves  rotated  until 
the  outer  ends  are  in  the  same  horizontal  plane.  The  vaginal 
lever  is  now  introduced,  the  vaginal  portion  resting  between 
the  two  half  catheters  which  are  in  the  bladder,  and  these 
halves  are  then  rotated  still  farther  until  the  spring  connecting 
their  outer  ends  can  be  adjusted.  The  split  vertical  bar  is  now 
fastened  on  the  catheter  sheath,  the  outer  end  of  the  vaginal 
lever  slipped  into  position  between  the  two  arms  of  the  vertical 


THE   SEGREGATOR  93 

bar,  the  pin  adjusted  to  keep  it  in  position,  and  the  spring  is 
hooked  onto  the  vaginal  lever. 

The  shoulders  of  the  patient  should  not  be  elevated  when  the 
segregator  is  used  and  the  catheter  sheath  should  be  directly 
in  the  mid-line  of  the  body.  That  portion  of  the  instrument 
outside  of  the  body  is  crudely  represented  by  a  triangle  whose 
superior  boundary  is  horizontal,  the  plane  bounded  by  its  sides 
being  vertical. 

The  bladder  is  now  washed  out  with  boric  solution  to  get  rid 
of  any  blood  which  might  flow  from  slight  abrasions  produced 
during  the  introduction  of  the  instrument,  and  the  first  few 
drops  which  escape  spontaneously  after  the  washing  is  com- 
pleted are  thrown  away.  The  suction  apparatus  is  now  at- 
tached and  a  partial  vacuum  produced  in  the  bottles,  after 
which  the  urine  escapes  as  it  is  expelled  from  the  ureters,  in 
little  spurts  of  from  two  to  ten  drops. 

Sometimes  temporary  inhibition  of  kidney  secretion  is  caused 
by  the  manipulations,  and  it  may  be  some  minutes  before  the 
urine  appears  although  it  can  be  hastened  by  having  the  patient 
drink  one  or  two  glasses  of  hot  water  after  the  apparatus  is  in 
place. 

The  most  annoying  feature  of  segregation  is  the  length  of  time 
needed  to  secure  satisfactory  specimens  for  comparative  ex- 
amination, patients  rarely  leaving  the  table  within  an  hour  and 
suffering  more  from  the  enforced  quiet  than  the  discomfort 
caused  by  the  instrument. 

Segregation  has  its  limitations  and  may  be  the  source  of  an 
occasional  error,  but  it  can  be  performed  without  difficulty  by 
any  one  who  cares  to  spend  an  hour  or  two  in  becoming  famiHar 
with  the  instrument  and  technique,  while  its  accuracy  and  value 
in  every  day  use  are  surprising. 

Cases  requiring  great  diagnostic  nicety  and  acumen  should 
be  referred  to  urological  specialists,  in  whose  hands  ureteral 
catheterization,  measurements  of  the  capacity  of  the  kidney 


94  SYMPTOMATOLOGY  AND   DIAGNOSIS 

pelvis,  collargol  injections,  and  radiograms  are  matters  of  daily 
occurrence. 

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HARRIS.— The  Best  Method  of  Collecting  the  Urine  from  the  Ureters  for 

Diagnostic  Purposes.     Ann.  Surg.,  igoo,  xxxii,  149. 
HARRIS,  M.  L. — A  New  and  Simple  Method  of  Obtaining  the  Urine  Separately 

from  the  Two  Kidneys  in  Either  Sex.     /.  Am.  M.  Assn.,  1898,  xxx,  236. 
HARTMAN,  H.  (first  described  and  presented  by). — ^Luy's  Segregator.     Am. 

d.  Mai.  d.  Org.  G.  U.,  1902,  xx,  717  and  926. 


CHAPTER  IV 

DISEASES  AND  INJURIES  OF  THE  VULVA 

The  greater  portion  of  the  vulva  is  covered  by  skin,  but  at 
the  inner  surface  of  the  labia  minora  this  changes  to  a  structure 
which  closely  resembles  mucous  membrane.  It  naturally 
follows  that  diseases  affecting  the  vulva  are  those  which  might 
affect  either  the  cutaneous  or  mucous  surfaces  of  any  other 
portion  of  the  body,  together  with  such  conditions  as  are  pe- 
culiar to  the  vulva  because  of  its  physiological  functions  and 
the  functions  of  the  organs  in  its  immediate  vicinity.  As 
examples  we  may  have  eczema  of  the  skin  of  the  vulva,  gonor- 
rhea of  the  mucosa,  injuries  from  copulation,  or  pruritus  from 
the  irritation  of  diabetic  urine. 

Vulvitis. — Inflammatory  processes  affecting  the  vulva  may 
be  of  any  degree  of  severity  from  the  ordinary  erythema  of 
chafing  to  the  violent  inflammation  of  a  virulent  gonorrheal 
infection. 

The  causes  of  vulvitis  are  traumatism,  chemical  irritation, 
and  infection. 

Under  traumatism  are  included  chafing,  scratching  which 
may  be  induced  by  the  itching  of  parasites  or  idiopathic  pruritus, 
and  excessive  coitus  and  masturbation.  Chemical  sources  are 
found  in  decomposing  smegma,  sebaceous  secretions,  and 
perspiration.  Chemical  irritation  is  probably  the  cause  of  the 
vulvitis  produced  by  diabetic  urine,  urine  or  feces  constantly 
escaping  from  fistulae,  the  leucorrheal  discharge  of  senile 
vaginitis  and  endometritis,  and  the  acrid  discharge  from 
breaking-down  carcinoma  of  the  uterus. 

Inoculation  with  infectious   micro-organisms  produces   the 
same  result   here  as  elsewhere   in  the    body,   and  erysipelas, 
7  97 


98  DISEASES   AND   INJURIES   OF  THE  VULVA 

abscesses  or  furunculosis  may  be  the  outcome,  but  the  most 
common  of  all  inflammatory  processes  is  gonorrheal  inflamma- 
tion of  those  portions  of  the  vulva  which  are  covered  by  mucous 
membrane.  This,  by  reason  of  its  irritating  qualities,  may  set 
up  a  violent  inflammation  of  the  skin  although  the  gonococci 
themselves  proliferate  upon  the  mucous  surface  only. 

Symptoms. — Burning  and  smarting,  increased  by  urination, 
is  the  first  and  predominant  symptom  of  vulvitis.  Severe  throb- 
bing is  present  in  furunculosis  and  deep-seated  inflammation 
such  as  abscess  formation  in  the  greater  vestibular  glands.  In 
mild  cases  transient  redness  is  present,  but  in  severe  forms  there 
is  a  raw  angry  appearing  excoriation.  In  children,  noma,  a 
form  of  gangrene  of  the  vulva,  is  a  rare  but  dangerous  type  of 
infection. 

The  discharge  varies  from  an  almost  colorless  serous  exudate 
in  early  cases  of  mild  type,  to  a  thick  creamy  or  greenish  pus 
in  the  very  severe  forms.  A  distinctly  purulent  discharge 
almost  invariably  is  gonorrheal,  but  in  small  delicate  children 
pus  may  be  present  in  the  discharge  without  specific  infection. 

Infection  of  the  greater  vestibular  glands  and  para-urethral 
ducts,  and  purulent  infection  of  the  urethra  are  almost  without 
exception  due  to  gonorrhea.  In  erysipelas  no  pus  is  present, 
but  the  rapid  spread  of  the  redness  and  its  well-defined  border 
are  characteristic,  as  is  its  appearance  during  the  puerperium. 
Diphtheritic  vulvitis  also  is  rare  except  during  the  puerperium, 
and  that  curious  but  violent  form  of  infection  giving  rise  to  the 
so-called  puerperal  ulcer  is  found  after  labor  only.  Care  must 
be  taken  to  distinguish  between  diphtheritic  and  streptococcic 
exudate  in  instances  of  vulvitis  characterized  by  the  formation 
of  membrane. 

A  microscopic  examination  should  be  made  in  every  instance 
of  purulent  vulvitis,  not  only  for  the  sake  of  a  correct  diagnosis 
but  also  in  order  that  precautions  may  be  taken  against  infect- 
ing others,  and  if  gonococci  are  discovered  the  patient  should 
be  informed  of  the  risk  of  accidental  inoculation  of  her  own  eyes. 


TREATMENT   OF  VULVITIS  99 

Herpes  can  scarcely  be  classified  as  an  inflammation,  but  the 
subjective  symptoms  closely  resemble  those  of  vulvitis,  and  the 
scratching  which  herpes  induces  may  readily  set  up  the  latter 
disorder.  The  appearance  of  any  herpetic  eruption  is  char- 
acteristic if  observed  before  the  irritation  produced  by  scratch- 
ing and  rubbing  the  parts  has  interfered  with  the  vesicles,  which, 
when  uninjured,  appear  like  a  series  of  small  water  bHsters 
resting  upon  a  moderately  inflamed  base. 

Eczema  of  the  vulva  is  often  associated  with  eczema  of  other 
portions  of  the  body  and  presents  the  usual  phenomena  of 
eczema  elsewhere,  viz.,  a  papular  or  vesicular  eruption  which 
itches  intensely,  the  appearance  of  a  watery  sticky  secretion 
which  dries  into  a  scab,  upon  the  removal  of  which  a  raw  weep- 
ing surface  remains.  Very  chronic  types  of  eczema  of  the  vulva 
are  sometimes  found  in  pruritus  without  eczema  being  present 
elsewhere. 

Treatment. — Mild  vulvitis,  not  produced  in  infection,  sub- 
sides quickly  if  the  source  of  irritation  can  be  removed  and  the 
inflamed  surfaces  properly  cleaned  and  protected.  Cleanli- 
ness must  be  secured,  but  plain  water  acts  as  an  irritant  to  an 
acutely  inflamed  skin  so  that  boric  acid  solution,  normal  salt 
solution,  or  a  weak  solution  of  bicarbonate  of  sodium  are  pref- 
erable when  secretions  are  to  be  removed.  Gently  wiping  the 
surface  with  oHve  oil  will  cleanse  it  as  well  as  washing  with 
watery  solutions,  and  it  has  the  advantage  of  producing  no 
irritation.  Protection  can  be  accomplished  by  simple  oint- 
ments, such  as  Ung.  aquae  rosas,  Ung.  zinc  oxid,  and  Acidi 
borici  in  Ung.  simplex,  and  these  are  more  efficient  if  applied 
upon  gauze  or  cotton  in  such  a  manner  as  to  separate  the  ad- 
jacent lips  of  the  vulva.  Protection  may  also  be  secured  by 
the  application  of  solutions  of  silver  nitrate  which  form  a  film 
of  albuminate  of  silver  upon  surfaces  that  are  denuded  of  their 
epithelium,  but  silver  nitrate  appKcations  sometimes  are 
painful  and  on  this  account  should  be  used  with  caution. 

Such  types  of  vulvitis  as  have  their  origin  in  incurable  con- 


lOO  DISEASES   AND   INJURIES   OF   THE  VULVA 

ditions,  like  the  discharge  from  advanced  carcinoma  of  the 
cervix,  can  be  palliated  by  the  above  methods,  but  cure  is  usually 
out  of  the  question. 

Gonorrheal  vulvitis  yields  readily  upon  that  portion  of  the 
mucous  surface  which  is  smooth  and  devoid  of  glands,  but  is 
recalcitrant  to  any  treatment  once  it  has  extended  to  the 
urethra,  para-urethral  ducts,  or  ducts  of  the  greater  vestibular 
glands.  Cleanliness  is  as  essential  in  this  type  as  in  non- 
specific vulvitis,  and  the  silver  salts  are  the  most  reliable  thera- 
peutic agents.  On  surfaces  such  as  the  vaginal  orifice,  the 
vestibule,  and  inner  surfaces  of  the  labia  minora,  which  are  not 
exquisitely  sensitive,  painting  with  a  lo  per  cent,  solution  of 
silver  nitrate  once  or  twice  weekly  is  effectual,  while  the  weaker 
but  non-irritating  organic  silver  preparations  may  be  used 
freely  in  the  urethra.  The  para-urethral  ducts  should  be  laid 
open  with  a  small  knife  and  fused  silver  nitrate  be  applied  upon 
a  fine  probe. 

Vulvitis  in  small  children  is  often  gonorrheal  in  character, 
but  that  type  of  child  which  the  older  clinicians  designated  as 
' 'scrofulous,"  is  peculiarly  prone  to  non-specific  vulvitis  which 
does  not  yield  until  the  existing  mal-nutrition  is  overcome  by 
fresh  air,  feeding,  and  iron. 

Vulvitis  caused  by  the  ordinary  pyogenic  organisms  should 
be  treated  here  as  pyogenic  infection  is  treated  elsewhere. 
Abscesses  and  furuncles  should  be  opened,  and  if  repeated  re- 
curronce  takes  place  in  spite  of  local  treatment  vaccination  with 
an  autogenous  vaccine  offers  the  most  hope  of  cure. 

Follicular  Vulvitis. — A  clear  cut  picture  is  usually  presented 
by  the  form  of  vulvar  inflammation  which  bears  the  above 
designation.  Small  pustules  surrounded  by  a  trifling  red  areola 
are  seen  scattered  over  the  skin  surface,  and  close  examination 
reveals  the  orifice  of  a  hair  follicle  at  the  summit  of  each  pustule. 
The  symptoms  are  those  of  vulvitis  in  general,  and  the  treat- 
ment consists  in  evacuation  of  the  contents  of  each  pustule, 


PRURITUS   VULV^ 


lOI 


followed  by  cleansing  and  protection  as  in  other  forms  of  the 
disease. 

Erysipelas,  diphtheria,  and  puerperal  ulcer  are  obstetric 
infections  and  are  dealt  with  sufficiently  in  text-books  on  that 
subject. 

Stenosis  of  the  Vulva. — There  are  two  forms  of  stenosis,  the 
congenital  and  the  acquired.     Congenital  stenosis  is  an  anomaly 
of  development  and  is  dis- 
cussed in  Chap.  XV. 

Acquired  stenosis  may  be 
the  result  of  cicatricial  con- 
traction following  severe 
injuries  or  burns,  but  is 
most  frequently  found  in 
young  children  in  whom 
the  labia  have  become 
agglutinated,  probably  by 
reason  of  a  very  early 
vulvitis  with  subsequent 
adhesion  of  the  apposed 
surfaces.  Such  adhesions 
are  separated  readily  with 
the  probe,  and  their  re-for- 
mation is  prevented  by  the 
introduction  of  gauze  be- 
tween the  labia  until  the 
surfaces  are  completely 
covered  with  epithelium. 
Cicatricial  stenosis  is  man- 
aged either  by  gradual  dila- 
tation or  plastic  operation,  according  to  the  degree  of  stenosis 
and  extent  of  surface  involved. 

Pruritus  Vulvae. — Pruritus  or  itching  of  the  vulva  in  most  in- 
stances is  purely  symptomatic  in  character.  It  is  found  with 
parasites,  pin  worms,  eczema,  and  kraurosis,  as  well  as  in  early 


Fig.  34. — Acquired    infantile    stenosis    of 
vulva  due  to  adhesion  of  the  labia. 


I02  DISEASES   AND   INJURIES    OF   THE  VULVA 

vulvitis.  In  a  few  cases  it  seems  to  be  a  local  neurosis  when  it 
is  termed  idiopathic,  although  Webster  claims  to  have  found 
microscopic  changes  in  the  nerve  endings.  A  mild  form  is 
present  in  many  women  during  menstruation  and  pregnancy. 
Severe  and  advanced  cases  always  are  associated  with  such  skin 
changes  that  it  is  impossible  to  determine  which  disorder  is 
primary  and  which  secondary.  The  skin  changes  consist  of 
a  leather-like  thickening  with  alternating  folds  and  fissures, 
the  skin  being  covered  by  a  dirty  gray  epithelium. 

No  case  should  be  considered  as  idiopathic  until  all  sources 
of  local  irritation  are  excluded,  and  every  case  of  pruritus  in 
elderly  women  should  be  suspected  of  having  a  diabetic  origin 
until  the  contrary  is  proven. 

Treatment. — Pruritus,  as  such,  needs  treatment  in  instances 
in  which  no  causative  lesion  can  be  discovered. 

The  itching  produced  by  eczema,  vulvitis,  and  other  tangible 
causes  is  cured  by  attention  to  the  primary  lesion  providing  the 
latter  is  curable,  but  itching  without  visible  skin  changes  is 
exceedingly  intractable  although  it  may  be  materially  alle- 
viated. The  internal  administration  of  nerve  sedatives  is  of 
value  as  a  palliative  measure  and  in  severe  cases  is  necessary  in 
order  to  secure  sleep  as  the  itching  is  most  intense  at  night. 
Sponging  with  water  as  hot  as  can  be  borne  allays  the  itching 
temporarily,  and  ointments  containing  cocaine  or  menthol  are 
useful  for  the  same  purpose.  The  itching  of  diabetes  is  alle- 
viated as  the  sugar  in  the  urine  diminishes  under  antidiabetic 
treatment. 

If  marked  hypertrophy  of  the  skin  surface  has  occurred, 
painting  with  tr.  of  iodine  at  intervals  of  five  or  six  days  causes 
exfoliation  of  the  thickened  epidermis,  and  the  same  result  may 
be  secured  by  the  daily  application  of  a  salicylic  acid  ointment 
containing  lo  to  20  grains  to  the  ounce.  After  exfoliation  the 
skin  sometimes  remains  normal  for  a  considerable  time  and  the 
intense  itching  is  measurably  relieved. 


CHANCRE  103 

The  Roentgen  rays  or  radium  applied  by  a  skillful  operator 
sometimes  give  great  relief  and  result  in  an  occasional  cure. 

In  intractable  cases  in  which  the  suffering  is  unbearable 
the  affected  skin  surfaces  may  be  removed  and  the  raw  area  be 
covered  by  flaps  of  healthy  skin  drawn  from  the  vicinity  by 
means  of  a  plastic  operation. 

Kraixrosis  Vulvae. — This  fortunately  rare  disease  is  un- 
doubtedly of  trophic  origin  and  consists  of  an  atrophy  of  the 
skin  about  the  vulva.  It  is  infrequent  before  the  menopause, 
and  in  young  women  is  one  of  the  undesirable  results  which 
sometimes  follows  the  induction  of  the  premature  menopause 
by  the  removal  of  the  ovaries.  The  labia  become  flattened, 
the  clitoris  atrophic,  and  the  vaginal  entrance  narrowed,  some- 
times to  such  a  degree  that  coitus  is  impossible.  The  appear- 
ance of  the  parts  suggest  senile  atrophy  carried  to  its  ultimate 
conclusion.  Pruritus  and  burning  are  sometimes  complained  of. 
The  condition  is  incurable  by  medical  treatment  and  if  the 
annoyance  is  severe  the  affected  areas  may  be  removed  as 
in  intractable  pruritus. 

Chancre. — Vulvar  chancre  is  found  most  frequently  on  the 
labia  majora  and  fourchette  although  any  part  of  the  external 
genitalia  may  be  infected. 

The  true,  hard,  or  Hunterian  chancre  appears  in  from  two  to 
six  weeks  after  exposure,  and  the  infection  is  inoculated  through 
an  abrasion  on  the  skin  or  mucous  surface,  this  abrasion  usually 
being  healed  before  the  specific  sore  appears.  Typically  the 
first  lesion  is  a  hard  papule,  brownish  in  color,  which  gradually 
becomes  eroded  on  its  surface  while  the  circumference  increases 
in  hardness. 

In  some  instances  no  surface  erosion  occurs,  the  papule  re- 
maining hard,  dry,  and  scaly  during  its  entire  existence,  while 
in  others  the  erosion  deepens  into  a  distinct  ulcer. 

The  characteristic  features  of  the  true  chancre  are  its  long 
period  of  incubation,  its  painlessness,  and  its  distinct  induration. 
While  it  is  never  safe  to  diagnose  syphilis,  even  from  a  perfectly 


I04  DISEASES   AND   INJURIES    OF   THE  VULVA 

characteristic  chancre,  the  specific  nature  of  such  a  lesion  may 
be  considered  as  tentatively  correct  if  the  inguinal  lymphatics 
draining  the  area  involved  show  painless  hard  enlargement  of 
one  or  more  glands,  this  induration  progressing  paripassu  with 
the  induration  of  the  primary  sore. 

Discovery  of  the  parasite,  the  spirochete  pallida,  in  the 
secretion  or  scrapings  from  the  surface  of  the  sore  is  positive 
evidence  of  its  specific  character.  General  lymphatic  enlarge- 
ment and  the  typical  skin  eruption  render  the  diagnosis  certain, 
but  by  the  time  these  secondary  symptoms  make  their  ap- 
pearance the  primary  sore  may  have  disappeared.  While  by 
some  it  is  thought  better  to  await  secondary  manifestations 
before  instituting  treatment,  it  is  imperative  to  arrive  at  a 
diagnosis  as  soon  as  possible  after  the  appearance  of  the  primary 
sore  in  order  that  the  infected  individual  may  be  warned  of  the 
risk  of  conveying  infection  to  others,  and  the  early  discovery 
of  the  parasite  now  renders  this  possible  even  before  the 
Wassermann  reaction  is  available  as  a  diagnostic  resource. 

Treatment. — The  general  treatment  of  syphilis  is  dealt  with 
at  length  in  text-books  upon  that  subject.  There  is  some 
difference  of  opinion  as  to  whether  chancre  is  merely  the  first 
manifestation  of  a  general  syphilitic  infection  and  whether, 
therefore,  local  treatment  has  any  effect  upon  the  disease,  but  it 
is  important  that  no  irritation  be  produced  by  the  use  of  caus- 
tics as  they  do  no  good  and  may  set  up  an  intractable  phagedenic 
ulceration.  Attention  to  cleanliness,  daily  cleansing  with  weak 
bichloride  solution,  or  the  use  of  calomel  as  a  dusting  powder 
may  be  all  that  is  called  for  in  the  way  of  attention  to  the 
primary  vulvar  sore,  although  some  syphilographers  are  in 
favor  of  excision  as  the  surest  means  of  removing  a  concentrated 
accumulation  of  spirochetes  from  the  body.  Altogether  it 
seems  likely  that  excision  of  the  chancre,  together  with  the 
earliest  possible  administration  of  salvarsan  or  neo-salvarsan 
by  approved  methods,  is  the  safest  and  surest  means  of  eliminat- 
ing the  primary  sore  and  starting  the  patient  on  the  road  to 


CHANCROID  105 

recovery  from  syphilitic  infection.  There  is  constantly  ac- 
cumulating evidence  that  none  of  the  arsenical  preparations, 
no  matter  how  used,  are  permanently  and  definitely  curative  in 
syphilis.  That  they  cause  rapid  disappearance  of  primary  and 
secondary  lesions  is  incontestable,  but  a  permanent  cure  without 
the  danger  of  future  recurrence  of  symptoms,  or  late  manifes- 
tations of  syphilis  of  the  central  nervous  system,  is  not  to  be 
secured  without  resort  to  mercury,  possibly  over  as  long  a  period 
as  was  thought  necessary  before  Salvarsan  was  brought  out. 

Chancroid. — The  soft  chancre,  or  chancroid,  offers  a  marked 
contrast  to  the  true  primary  syphilitic  sore.  Whether  chan- 
croid is  caused  by  a  specific  organism  or  by  inoculation  with  the 
ordinary  pus-producing  organisms  is  not  definitely  known,  but 
its  behavior  is  so  much  at  variance  with  the  lesions  caused  by 
staphylococci  for  example,  that  it  seems  probable  it  is  a  disease 
by  itself  with  a  specific  germ,  the  bacillus  Ducrey,  as  its  cause. 
The  spirochete  of  syphilis  is  never  found  in  the  secretions  from 
the  soft  chancre. 

Chancroid  makes  its  appearance  in  from  two  to  five  days  after 
exposure  as  a  small  painful  pustule  which  rapidly  assumes  the 
characteristics  of  an  ulcer  with  sharp-cut  edges.  Its  base  has 
a  dirty  necrotic  appearance,  and  it  secretes  a  thin  purulent 
discharge.  These  ulcers  are  frequently  multiple  and  are  auto- 
inoculable,  in  both  of  which  respects  they  are  unlike  true 
chancre.  Chancroid  may  remain  as  a  distinct  round  ulcer, 
spread  superficially  over  the  surface,  or  produce  deep  sloughing. 
Lymphadenitis  of  the  inguinal  chain  of  glands  may  take  place 
with  suppuration  and  necrosis,  a  condition  which  is  known  as 
chancroidal  bubo. 

Treatment. — Mild  forms  of  chancroid  heal  in  a  few  days  under 
local  antiseptic  treatment,  with  care  to  prevent  contact  of 
the  discharge  with  other  portions  of  the  vulva.  The  parts 
should  be  washed  with  1-2000  or  1-3000  bichloride  of  mercury 
solution  several  times  daily,  then  dried  and  dusted  with  a  powder 
composed  of  one  part  of  calomel  to  four  or  five  of  bismuth  sub- 


Io6  DISEASES   AND   INJURIES   OF  THE  VULVA 

nitrate,  and  the  labia  kept  apart  with  a  piece  of  absorbent 
cotton  covered  with  the  same  powder. 

Serpiginous  or  phagedenic  ulceration  should  be  met  by 
thorough  destruction  of  the  base  of  the  ulcer,  a  form  of  treat- 
ment which  is  so  painful  as  to  necessitate  local  and  at  times  even 
general  anaesthesia.  Pure  carbolic  acid  applied  to  the  ulcer  only 
and  neutralized  within  one  minute  by  alcohol,  or  in  the  worst 
cases  destruction  of  the  ulcer  by  the  actual  cautery,  is  de- 
manded. This  should  be  followed  by  the  constant  application 
of  compresses  moistened  with  boric  acid  or  weak  bichloride 
solution.  Such  radical  treatment  should  be  used  but  once,  but 
the  destruction  should  be  thorough  and  complete. 

Condylomata. — Condylomata  are  of  two  forms,  fiat  and 
acuminate. 

The  flat  condylomata  are  true  syphilitic  lesions  and  are 
nothing  more  or  less  than  the  mucous  patches  which  are  so 
familiar  as  a  late  secondary  syphihtic  manifestation  in  the 
mouth  and  throat,  and  their  intensely  infectious  character  must 
be  borne  in  mind.  The  treatment  is  that  of  syphilis  in  general, 
together  with  the  local  application  once  or  twice  a  week  of  silver 
nitrate  solution  in  the  strength  of  from  lo  to  20  grains  to  the 
ounce.  The  parts  affected  should  be  bathed  frequently  with 
a  weak  bichloride  of  mercury  solution  in  the  interval  between 
treatments. 

Pointed  or  acuminate  condylomata  are  warty  vegetations 
due  to  hypertrophy  of  the  papillary  layer  of  the  skin  and  a*re 
found  most  frequently  in  patients  who  have  gonorrhea  although 
by  no  means  confined  to  them.  They  may  be  situated  upon  any 
portion  of  the  vulva  and  in  bad  cases  they  not  only  cover  the 
vulva  but  spread  to  surrounding  parts.  Their  color  varies 
from  a  dull  grayish  pink  to  a  bright  red,  depending  upon  the 
blood  supply,  and  their  general  shape  and  appearance  is  that  of 
moist  succulent  warts,  sometimes  pedunculated  but  usually 
sessile.  Although  commonly  known  as  venereal  warts  and 
often  occurring  during  gonorrhea  and  sometimes  during  syphilis. 


CONDYLOMATA 


107 


^^^tKf     .^^^''^^^^^^^^^^^HSSik'^l^^^. 

^^■1;  ""^v^  '^P^^E^Bl^  '"^^  '^M  'I^H 

^^mu.S^^Kik^ ^^^^^?itm^^^\  ''WS^^^^^^^^F 

^^^mm  H^-^    m^^^ 

-  W 

Fig.  ^$. — Acuminate  condylomata. 


io8 


DISEASES   AND   INJURIES    OF   THE  VULVA 


they  are  diagnostic  of  neither  disease  and  may  occur  in  persons 
entirely  free  from  venereal  taint. 

Treatment. — Small  venereal  warts  will  frequently  disappear 
if  powdered  with  calomel  or  alum  and  kept  perfectly  dry. 
Pedunculated  growths  may  be  snipped  off  but  are  Hkely  to  recur 
unless  their  bases  are  cauterized.  The  removal  of  extensive 
condylomatous  masses  is  rather  formidable  on  account  of  the 

profuse  hemorrhage  and 
should  be  undertaken  only 
under  general  anaesthesia. 
As  they  are  soft  they  may 
be  removed  with  the  scis- 
sors and  sharp  curette  and 
the  bleeding  controlled  by 
hot  sponging  and  pres- 
sure. Every  recurrence 
should  be  met  by  prompt 
removal  and  cauterization. 
While  chemical  caustics, 
such  as  glacial  acetic  acid, 
chromic  acid,  nitric  acid, 
etc.,  are  useful,  the  actual 
cautery  lightly  applied  is 
just  as  efficient  and  its 
effects  are  far  more  easily 
controlled. 


Fig.  36. — Acute  Bartholinian  abscess. 


Bartholinitis. — Inflammation  of  the  greater  vestibular  gland 
and  duct  is  almost  pathognomonic  of  gonorrheal  infection. 
During  acute  gonorrheal  vulvitis  the  outlet  of  the  duct,  just 
outside  of  the  remnants  of  the  hymen,  may  often  be  seen  dis- 
charging pus.  After  the  subsidence  of  the  acute  inflammation, 
its  telltale  mark  is  left  for  an  indefinite  period  in  the  shape 
of  a  tiny  red  areola  about  the  orifice  of  the  duct. 

Acute  inflammation  of  the  gland  itself  takes  place  as  the 
result  of  extension  from  the  duct,  and  if  the  latter  becomes 


TREATMENT   OF  BARTHOLINITIS  IO9 

occluded  an  abscess  of  the  gland  results.  Such  an  abscess  may 
evacuate  itself  through  the  duct,  but  more  frequently  it  breaks, 
either  just  within  or  without  the  vulvar  orifice  with  immediate 
relief  from  all  symptoms.  Recurrence  takes  place  sooner  or 
later  so  that  a  series  of  abscesses  is  the  rule  unless  radical 
treatment  is  instituted. 

Symptoms. — The  typical  symptoms  of  acute  inflammation 
are  present  in  the  affected  gland.  The  labium  of  the  corre- 
sponding side  is  much  swollen  owing  to  its  loose  texture,  and  this 
swelhng  extends  well  up  into  the  vagina  on  the  same  side. 
The  pain  is  severe  from  the  onset  and  is  greatly  aggravated  by 
standing  and  walking.  The  condition  can  scarcely  be  mistaken 
for  anything  else  if  the  shape  and  location  of  the  gland  are 
borne  in  mind. 

•  Treatment. — Under  the  use  of  hot  compresses  the  duct  may 
re-open  and  the  abscess  evacuate  itself,  but  such  an  outcome  is 
unusual.  Free  incision  is  indicated  through  the  most  tense 
portion  of  the  swelling,  either  on  the  inner  side  of  the  labium 
or  just  within  the  hymen.  This  may  be  done  under  local 
anaesthesia  in  most  instances  but  in  very  nervous  patients 
general  anaesthesia  is  necessary.  It  is  sometimes  advised  to 
extirpate  the  gland,  but  the  after-effects  are  less  painful  and 
the  risks  of  severe  infection  minimized  if  extirpation  is  deferred 
until  the  acute  inflammation  has  been  overcome  by  preliminary 
evacuation  of  the  pus. 

Inasmuch  as  recurrence  is  the  rule,  eventual  removal  of 
the  gland  should  be  practised  whether  it  has  been  incised  or 
opened  spontaneously,  as  should  also  be  done  in  chronic  in- 
fection which  leads  either  to  palpable  thickening  of  the  gland 
or  its  conversion  into  a  cyst. 

For  this  operation  general  anaesthesia  is  necessary.  An 
incision  is  made  down  the  inner  side  of  the  labium  and  the 
gland  dissected  out  intact  if  possible.  Bleeding  from  the 
veins  of  the  vestibule  is  free  and  is  checked  by  suturing  the 
bleeding  points  at  the  bottom  of  the  wound.     The  incision 


110  DISEASES   AND   INJURIES   OF  THE  VULVA 

should  be  closed  with  superticial  sutures  leaving  the  lower  end 
of  the  wound  open  for  drainage.  If  all  of  the  gland  cannot  be 
removed  that  portion  which  is  left  should  be  disinfected  with 
pure  carbolic  acid,  neutraHzed  with  alcohol,  and  the  entire 
wound  packed  and  allowed  to  granulate  from  the  bottom. 

Tumors. — Tumors  of  the  vulva  are  relatively  rare.  They 
comprise  such  tumors  as  arise  in  similar  histological  structures 
elsewhere  in  the  body.  Lipomata,  fibromata,  epitheliomata, 
and  sarcomata  may  occur.  Sebaceous  cysts,  masses  of  vari- 
cose veins,  hydrocele  of  the  canal  of  Nuck,  and  hernia  extend- 
ing into  the  labium  all  give  rise  to  enlargements  not  composed 
of  new  tissue,  but  simulating  tumor  formation. 

Lipomata  may  be  distinguished  here  as  elsewhere  by  their 
peculiar  consistency,  lobulated  form,  and  the  pig-skin  appear- 
ance over  them  when  traction  is  made.  Fibromata  are  hard 
and  usually  more  or  less  pedunculated.  Sarcomata  are  very 
rare  and  usually  melanotic  in  character.  Epitheliomata  are 
usually  wart-like,  covered  with  a  scab  in  their  very  earliest 
stages,  and  grow  rapidly  as  hard  infiltrating  tumors  which 
break  down  as  they  advance.  There  is  coincident  enlargement 
of  the  neighboring  lymph  glands. 

Sebaceous  cysts  are  somewhat  difficult  to  distinguish. 
They  are  movable,  encapsulated,  not  lobulated,  semi-fluctuat- 
ing, and  moreover  the  opening  of  the  duct  may  sometimes  be 
distinguished  upon  the  surface. 

Varicose  veins  are  readily  diagnosed  by  their  color,  promi- 
nence when  the  patient  assumes  the  standing  position,  and 
compressibility. 

Hydrocele  of  the  canal  of  Nuck  manifests  itself  as  a  fluctu- 
ating swelling,  not  disappearing  upon  pressure,  which  follows 
the  line  of  the  round  ligament  into  the  inguinal  canal. 

Inguinal  hernia  extending  into  the  labium  is  usually  reducible, 
gives  an  impulse  on  coughing,  and  its  neck  can  be  traced  into 
the  inguinal  canal. 

The  benign  tumors,  sebaceous  cysts,  and  hydrocele  of  the 


URETHRAL   CARUNCLE  III 

canal  of  Nuck  may  all  be  treated  by  excision  if  troublesome. 
Varicose  veins  may  be  ligated  under  the  same  circumstances. 

Malignant  growths  should  be  removed  far  beyond  their 
apparent  hmits  if  dissemination  has  not  already  occurred. 
In  cancer  the  inguinal  lands  must  be  removed  simultaneously, 
but  without  much  hope  of  success  if  they  are  palpably  enlarged. 
Involvement  of  the  liver  or  melanotic  patches  elsewhere  upon 
the  body  renders  operation  for  sarcomata  perfectly  useless. 
Inoperable  mahgnant  growths  should  be  submitted  to  X-ray 
or  radium  treatment.  Such  treatment  usually  fails  but  an 
occasional  cure  fully  justifies  its  use. 

Urethral  Canincle. — The  name  urethral  caruncle  is  appHed 
to  a  small  tumor  which  makes  its  appearance  at  the  external 
orifice  of  the  urethra.  In  appearance  it  is  not  unHke  a  red 
raspberry,  and  it  is  usually  attached  to  the  wall  of  the  urethra 
by  a  sessile  base.  Two  varieties  are  noted  clinically,  one  of 
which  is  excessively  painful.  The  other  is  not  so  painful 
but  bleeds  freely  when  handled.  They  may  appear  at  any  time 
of  life  although  somewhat  more  frequent  after  the  menopause. 
They  must  be  distinguished  from  prolapse  of  the  urethral 
mucosa,  the  swelKng  from  the  latter  being  perceptible  about 
the  entire  ring  of  the  external  urethral  orifice,  while  caruncles 
spring  from  a  distinct  base  which  occupies  only  a  portion  of 
its  circumference. 

The  treatment  is  excision  of  the  tumor  down  to  healthy 
tissue  and  suture  of  the  resulting  wound  if  large  or  cauteriza- 
tion if  the  base  is  small.  Local  anaesthesia  may  be  used  if  the 
base  is  small,  but  general  anaesthesia  is  required  when  it  is 
large.  There  is  no  portion  of  the  body  in  which  cocaine 
anaesthesia  should  be  used  more  circumspectly  than  about  the 
urethra,  and  in  large  vascular  caruncles  its  use  hypodermatically 
is  distinctly  dangerous.  The  wound  left  is  often  much  larger 
than  would  be  expected,  and  the  hemorrhage  difficult  to  control 
even  by  suture  as  the  tissues  are  friable  and  deep  sutures 
may  occlude  the  urethra. 


112 


DISEASES    AND   INJURIES    OF   THE  VULVA 


Vaginismus. — Vaginismus  is  a  spasm  of  the  muscles  which 
close  the  vaginal  orifice.  In  its  pure  form  it  is  strictly  a  neurosis 
which  manifests  itself  whenever  coitus  is  attempted,  thus  making 


Fig.  37. — Hirst's  operation  for  vaginismus.  An  incision  is  made  in  each 
vaginal  sulcus  which  meet  in  the  midline  at  the  fourchette  and  e.xtend  posteriorly 
toward  the  anus. 

penetration  by  the  male  organ  impossible.  In  some  instances 
attempts  at  digital  or  specular  examination  are  rendered  difficult 
or  impossible,   the  vaginal  orifice  contracting  spasmodically 


VAGINISMUS 


113 


whenever  approached.  The  spasm  is  always  severe  enough 
to  be  painful  and  is  often  positively  unbearable.  In  extreme 
cases  the  muscles  of  the  anterior  abdominal  wall  are  spas- 


FiG.  ^S. — Hirst's  operation  for  vaginismus.     The  incisions  are  sutured  trans- 
versely.    First  suture  inserted. 

modically  contracted  as  well  as  those  of  the  vulva.  A  much 
milder  form  of  spasm  is  met  with  occasionally  in  affections  of 
the  genitaha  which  render  intercourse  painful,  the  spasm  under 


114 


DISEASES  AND   INJURIES   OF   THE  VULVA 


these  circumstances  being  protective  in  character.  This  is 
sometimes  found  with  urethral  caruncle,  vulvitis,  inflamed 
remnants  of  the  hymen,  kraurosis  vulvae,  and  inflammation  or 
prolapse  of  the  tubes  and  ovaries. 

Treatment. — A  careful  search  should  be  made  for  any  organic 
lesions  which  might  be  responsible  for  painful  intercourse.     The 


Fig.  39. — Hirst's  operation  for  vaginismus.     All  sutures  inserted. 

cure  of  such  a  lesion  results  in  the  cure  of  the  spasm.  Par- 
ticular attention  should  be  given  to  the  small  tags  left  after 
rupture  of  the  hymen,  as  these  are  sometimes  as  sensitive  as 
neuromata,  and  also  to  the  possibility  of  a  prolapsed  ovary, 
which,  as  pointed  out  by  Sutton  and  Giles,  is  always  hyper- 
aesthetic. 


VAGINISMUS 


115 


Fig.  40. — Hirst's  operation  for  vaginismus.     All  sutures  tied.     The  vulva  gapes. 


Il6  DISEASES   AND  INJURIES   OF  THE  VULVA 

The  neurotic  cases  are  sometimes  psychic  in  their  origin,  and 
one  successful  intercourse  may  cause  permanent  cessation  of 
the  trouble  merely  by  demonstrating  that  intercourse  is 
possible.  In  the  greater  number  of  instances  an  operation  is 
required  which  will  diminish  the  power  of  the  muscles  concerned 
in  the  spasm,  and  this  is  accomplished  by  a  simple  operation 
described  by  Hirst. 

An  incision  is  made  in  each  vaginal  sulcus  extending  an 
inch  or  more  up  the  vaginal  wall,  the  two  incisions  meeting 
externally  in  the  mid-line  at  the  fourchette.  These  inci- 
sions are  sufficiently  deep  to  sever  the  anterior  edge  of  the 
levator  muscles.  From  the  fourchette  a  single  incision  extends 
in  the  mid-Hne  outward  and  posteriorly  toward  the  anus. 
When  these  incisions  are  completed  they  resemble  a  small 
median  perineal  laceration  with  an  extension  upward  along  each 
sulcus.  The  incisions  are  then  sutured  transversely,  and  the 
author  can  verify  Hirst's  statement  that  even  the  most  in- 
tractable cases  are  cured  by  its  performance. 

Parasites. — The  pediculosis  pubis  or  crab  louse  is  the  com- 
monest parasite  infesting  the  external  genitalia.  It  is  some- 
what larger  than  the  ordinary  head  louse  and  considerably 
broader,  its  shape  giving  rise  to  the  vulgar  name  of  crab.  The 
nits  are  deposited  upon  the  hairs  near  their  bases  and  are  closely 
glued  to  them.  Not  only  the  hair  on  the  mons  pubis,  but  the 
eyebrows,  axillary  hair,  and  that  upon  the  legs  may  become 
infected. 

The  parasites  may  be  acquired  through  sexual  intercourse, 
from  toilet  seats,  and  even  from  public  conveyances.  Their 
presence  gives  rise  to  intense  itching  and  sometimes  to  curious 
bluish  areas  upon  the  skin  known  as  maculae  cerulae.  Inspec- 
tion alone  discloses  the  presence  of  nits  upon  the  hair  of  the 
region  involved. 

The  treatment  is  frequent  bathing  of  the  affected  parts  with 
solutions  of  bichloride  of  mercury  in  the  strength  of  from  J^so 
to  J^oo  provided  the  area  involved  is  not  too  great.     Ung. 


rNJURIES    OF   THE  VULVA  II7 

hydrarg.  is  also  effectual  but  nasty,  and  sometimes  irritating  to 
sensitive  skins. 

The  pin  worm  or  oxyuris  vermicularis  occasionally  migrates 
from  the  anus  to  the  vulva,  where  it  may  be  seen  as  a  narrow 
white  thread  usually  less  than  i  cm.  in  length.  Treatment 
should  be  directed  to  its  original  seat  in  the  large  intestine  by 
means  of  enemata  of  infusion  of  quassia,  while  those  worms  which 
have  migrated  may  be  destroyed  by  the  external  application  of 
bichloride  solutions  as  recommended  for  pediculosis. 

Injuries  of  the  vulva  may  be  caused  by  kicks  or  blows,  by  fall- 
ing astride  of  blunt  or  sharp  objects,  by  forcible  coitus,  and 
by  parturition. 

Injuries  during  parturition  are  usually  associated  with  other 
and  more  important  injuries  to  the  vaginal  outlet  and  pelvic 
diaphragm. 

All  injuries  to  the  vulva,  however  produced,  fall  naturally 
into  the  surgical  classification  of  incised,  lacerated,  and  con- 
tused wounds,  and  their  importance  is  dependent  largely  upon 
the  vascularity  of*  the  parts  and  the  hemorrhage  which  ensues 
upon  injury.  Contusions  of  the  vulva  produced  by  blunt  force 
often  rupture  some  of  the  veins,  and  o^dng  to  the  softness  and 
elasticity  of  the  tissues  there  may  be  an  enormous  hsematoma 
with  no  external  wound. 

Open  injuries  about  the  region  of  the  urethra  and  vestibule 
may  result  in  excessive  external  hemorrhage  from  rupture  of  the 
veins  of  the  bulb.  This  is  Hkely  to  take  place  during  a  diffi- 
cult labor  and  the  resulting  bleeding  is  one  of  the  overlooked 
sources  of  post-partum  hemorrhage. 

Laceration  of  the  hymen  during  the  first  intercourse  may  be 
responsible  for  prolonged  and  persistent  hemorrhage,  and  at- 
tempted rape  upon  young  girls  is  productive  of  severe  lacera- 
tion and  serious  blood  loss. 

Treatment. — Haematomata  should  be  treated  by  rest  and 
pressure  until  it  is  apparent  whether  or  no  they  will  be  absorbed. 
If  absorption  does  not  occur,  they  should  be  evacuated  under 


Il8  DISEASES   AND   INJURIES   OF   THE  VULVA 

rigid  aseptic  precautions.  The  treatment  of  open  wounds 
depends  upon  their  character.  Clean  cut  wounds  should  be 
sutured  if  aseptic,  and  drained  if  their  condition  is  in  doubt. 
Owing  to  the  free  blood  supply,  suturing  of  wounds,  even  when 
there  is  considerable  bruising  and  damage  to  the  surrounding 
tissues,  is  permissible  about  the  vulva  providing  infection  is  not 
present.  Isolated  vessels  should  be  ligatured,  but  deep  catgut 
sutures  most  readily  control  the  bleeding  which  sometimes 
seems  to  proceed  from  all  portions  of  vulvar  wounds. 

Lacerations  produced  by  labor  ordinarily  should  be  repaired 
at  once,  together  with  the  associated  injuries  to  the  pelvic  floor. 

REFERENCES 

SINCLAIR. — Investigations  in  Vulva-vaginitis.  Arch,  of  Pediat.,  1914,  xxxi,  29. 
BERKELEY  AND  BONNEY.— Leucoplakic  Vulvitis  and  Its  Relation  to  Krau- 

rosis  Vulvae  and  Carcinoma  Vulvae.     Brit.  M.  J.,  1909,  ii,  1739. 
JACK. — Vaccine   Therapy  in   the   Treatment   of   Gonococcal   Vulvovaginitis. 

Glasgow  M.  J.,  19 1 3,  Ixxx,  84. 
EVANS,  J. — Some  Practical  Points  Relating  to  the  Causation  and  Treatment 

of  Pruritus  Vulvae.     Clin.  Journal,  191 2,  xl,  182. 
GIBBONS.— Pruritus  Vulvae.     Brit.  Med.  Jour.,  191 2,  i,  469. 
WALTHARD. — Ueber  den  psychogenen  Pruritus  Vulvae  and  seine  Behandlung. 

Deutsch.  Med.  Woch.y  191 1,  xxxvii,  831. 
SCHUBERT. — Ueber  die  neue  Behandlungsmethode  des  essentiellen  Pruritus 

Vulvae  und  anderer  Sakralneurosen.     Muench.  Med.  Woch.,  191 1,  Iviii,  745, 
STEIN. — Pruritus  Vulvae.     Urol.  &  Cutan.  Review,  1913,  xvii,  22. 
KIOLIN,  C.  F.— Kraurosis  Vulvae.     N.  York.  M.  J.,  191 2,  xcv,  128. 
BOLLAG,  K. — Ulcus    gummosum    Vaginae  et  Vulvae.     Corr.  Bla.  f.  Schweiz. 

Aerzte,  1914,  xliv,  1068. 
HISS  AND  ZINSSER.— Text-book  of  Bacteriology.     19 10.     Bacillus  Ducrey, 

540. 
VOGT. — Beitrag  zu  den  Melanosarkomen  der  Klitoris.     Arch.  f.  Gyn.,  1913, 

xcix,  364. 
LEWERS.— Sarcoma  of  the  Vulva.    Proc.  Roy.  Soc.  Med.,  1910,  iv;  Ohst.  &* 

Gyfi.  Sec,  64. 
STURMDORF. — Lipoma  of  the  Labium  Majus.     A7n.  J.  of  Ohst.,  1910,  Ixi,  311. 
DANIELS. — Die    elephantiatische   Tuberkulose   der   Vulva.     Monats.  f.   Geh. 

und  Gyn.,  1913,  xxxvii,  65. 
KRUSEN,  WILMER. — Varicose  Veins  of  the  Vulva  Complicating  Pregnancy. 

Am.  Gyn.  b"  Ohst.  /.,  1910,  xvii,  304. 


REFERENCES  II9 

RUPPRECHT. — Erfahrungen  iiber  das  Vulvakarzinom.     Zeitsch.  f.  Geh.  und 

Gyn.,  191 2,  Ixxii,  664. 
TENNEY,  B. — Tumor  of  the  Meatus  Urinarius  in  the  Female.     Ann.  of  Surg., 

1914,  Ix,  359. 
ROTHE. — 1st  beim  Vaginismus  eine  blutige  Erweiterung  Notwendig?     Zeitsch. 

/.  Geh.  und  Gyn.,  1913,  Ixxiii,  479. 
OBERLANDER. — Zur  Behandlung  des  Vaginismus  Mittels  eines  neuen  Scheiden- 

dilatators.     Zentralb.f.  Gyn.,  igog,  xxxiii,  178. 
TAUSSIG. — The  Prognosis  of  Cancer  of  the  Vulva.    Interstate  M.   /.,  1912, 

xix,  1052. 
REICH,  J. — Zur  Kenntnis  des  Haematoma  Vulvo-vaginale.     Wein.  Klin.  Woch., 

1 910,  xxiii,  1069. 


CHAPTER  V 

INJURIES  TO  THE  PERINEUM  AND  PELVIC 
DIAPHRAGM 

Before  taking  up  the  study  of  injuries  to  the  pelvic  diaphragm 
the  student  should  refer  to  the  anatomy  of  the  parts  and  fix  in 
mind  the  fact  that  the  term  '^perineal  body"  applies  to  a  limited 
portion  of  that  structure  only.  Unless  this  is  done  much  con- 
fusion is  likely  to  result  because  of  the  popular  use  of  the 
phrase  ''laceration  of  the  perineum,"  which  is  applied  not 
only  to  injuries  which  involve  the  perineal  body,  but  also  to  those 
involving  the  more  important  levator  ani  muscles  and  the 
fascia  covering  them.  The  latter  injuries  frequently  extend 
far  up  the  posterior  and  lateral  walls  of  the  vagina  and  may 
not  involve  the  perineal  body  at  all.  Injuries  to  the  anterior 
vaginal  wall  and  the  vesico-vaginal  plate  of  fascia  are  quite 
as  productive  of  trouble  as  those  of  the  posterior  wall,  but 
they  are  often  unrecognized  at  the  time  of  their  occurrence  be- 
cause they  are  Hkely  to  be  sub-mucous  rather  than  open. 

"Laceration  of  the  perineum"  applies  to  tears  which  invade 
any  part  of  the  true  anatomical  perineum,  and  the  term  is  not 
limited  to  the  physiologically  insignificant  injuries  that  involve 
the  small  body  of  tissue  lying  between  the  anus  and  vulvar 
orifice. 

TYPES   OF   INJURY 

Perineal  lacerations  are  divided  into  complete  and  incom- 
plete according  to  whether  the  sphincter  ani  muscle  is  or  is  not 
divided. 

Incomplete  lacerations  are  of  two  distinct  types.  The  first 
begins  on  the  posterior  vaginal  wall  just  within  the  hymen. 


1 20 


TYPES  OF  PERINEAL  INJURY  121 

extends  through  the  fourchette,  and  separates  the  two  halves 
of  the  perineal  body,  dividing  the  external  skin  for  a  variable 
distance  toward,  but  not  through,  the  sphincter  ani.  This  tear 
is  fairly  in  the  median  line  and  if  unrepaired  leaves  a  gaping 
vaginal  introitus,  but  it  in  no  way  involves  the  supporting  struc- 
tures of  the  pelvic  diaphragm  and  is  therefore  physiologically 
unimportant. 

The  second  begins  higher  up  in  one  or  both  vaginal  sulci  and 
extends  downward  to  the  perineal  body,  where  it  turns  toward 
the  mid-line.  Here  it  may  end  without  passing  through  the 
skin,  but  more  commonly  it  sphts  the  perineal  body  in  the  same 
manner  as  the  first  and  extends  for  a  variable  distance  toward 
the  anus.  This  form  of  laceration  may  penetrate  the  mucous 
membrane  and  skin  only,  or  it  may  go  more  deeply,  tearing 
through  the  levator  and  its  fascia.  When  internal  only,  that 
is,  when  it  does  not  pass  through  the  skin,  it  is  overlooked  al- 
most without  exception.  If  unrepaired  this  tear  deprives  the 
rectum  of  its  support  and  causes  the  anus  to  drop  backward 
beyond  its  normal  distance  from  the  posterior  edge  of  the 
pubis.  Intra-abdominal  pressure  then  operates  upon  an  orifice 
imperfectly  closed  and  the  various  forms  of  prolapse  of  the 
pelvic  structures  are  initiated. 

Other  injuries  to  the  structures  at  the  pelvic  outlet  may  be 
sustained  in  connection  with  these,  but  they  are  much  less 
common.  The  perineal  body  may  be  forced  away  from  the 
vagina,  the  resulting  tear  being  transverse,  and  the  lateral  ends 
of  such  a  laceration  may  extend  high  up  into  the  labium  on 
either  side.  The  fascia  between  the  vagina  and  bladder  may 
be  torn  without  injury  to  the  vaginal  mucosa,  and  a  tear  may 
start  in  the  space  between  the  urethra  and  superior  ramus, 
extending  into  the  vestibular  bulb  and  giving  rise  to  severe 
hemorrhage  at  the  time  of  its  occurrence. 

A  complete  laceration  is  merely  an  extension  of  a  simple, 
incomplete,  mid-line  tear  through  the  sphincter  of  the  anus. 
If  the  injury  is  severe,  it  may  extend  for  an  inch  or  more  up 


122       INJURIES    TO    THE   PERINEUM   AND   PELVIC   DIAPHRAGM 

the  recto-vaginal  septum,  but  very  rarely  is  it  associated 
with  the  characteristic  second  form  of  incomplete  tear.  This 
accounts  for  the  chnical  fact  that  complete  perineal  laceration 
is  but  infrequently  complicated  by  prolapse  of  the  uterus,  cys- 
tocele,  or  rectocele,  the  fundamental  disability  being  limited 
to  incontinence  of  gas  and  feces. 

Etiology.- — Injuries  to  the  pelvic  floor  usually  are  produced 
during  the  passage  of  the  foetal  head,  but  they  may  be  caused  by 
rapid  forcible  delivery  of  the  shoulders,  or  an  insignificant  tear 
may  be  converted  into  a  deep  one  in  the  same  manner.  A  large 
head  or  small  vagina  predisposes  to  injury.  Persistent  occipi to- 
posterior  position  makes  injury  more  probable  by  presenting  a 
larger  diameter  of  the  foetal  head  for  engagement  at  the  pelvic 
outlet. 

Forcible  delivery  and  delivery  early  in  the  second  stage  before 
the  soft  parts  have  become  thoroughly  dilated  are  prolific 
sources  of  laceration.  The  forceps  blades  may  cut  into  the 
vaginal  wall  and  so  initiate  a  tear  which  becomes  very  extensive 
by  its  continuation  externally. 

As  has  been  stated,  complete  lacerations  usually  are  in  the 
mid-Hne  and  are  not  associated  with  deep  lateral  tears,  the 
probable  explanation  lying  in  the  fact  that  lateral  tears  which 
pass  through  the  levator  allow  the  rectum  to  drop  posteriorly 
and  thus  escape  injury.  Ordinary  complete  tears  seem  to  be 
caused  by  rapid  escape  of  the  head  just  as  it  is  being  delivered, 
the  force  which  starts  the  tear  acting  excessively  at  this  point 
by  reason  of  the  suddenness  of  the  expulsion. 

Secondary  Results. — As  severed  muscles  tend  to  retract, 
the  surfaces  which  are  torn  apart  remain  separated,  and  the 
healing  process  consists  in  epithelization  of  such  raw  surfaces  as 
are  left  rather  than  their  proper  union.  If  the  tear  is  small  and 
in  the  median  line  no  harm  results.  If  through  the  anal  sphinc- 
ter, its  ends  retract  until  that  muscle  forms  a  straight  line  pos- 
terior to  the  anus.  If  the  injury  involves  the  supporting 
structures,  the  anus  is  displaced  posteriorly,  the  anterior  and 


CYSTOCELE  1 23 

posterior  vaginal  walls  no  longer  are  held  in  contact,  and  a 
relaxed  vaginal  outlet  is  the  result. 

If  a  woman  with  a  normal  pelvic  floor  be  examined  in  the 
standing  position  and  asked  to  strain  or  bear  down,  the  posterior 
and  anterior  vaginal  walls  will  be  found  firmly  in  contact  with 
each  other.     If  one  with  an  injured  pelvic  floor  is  examined 


Fig.  41. — Secondary  result  of  injury  to  pelvic  diaphragm.     Huge  cystocele, 

beginning  rectocele. 

under  the  same  circumstances,  a  protrusion  is  noticed  either  of 
the  bladder  anteriorly,  the  rectum  posteriorly,  or  both. 

The  anterior  protrusion  consists  of  the  posterior  bladder  wall, 
covered  by  vaginal  mucosa.*^.  This  protrusion  is  known  as  a 
cystocele  and  may  be  caused  by  the  loss  of  support  normally 


124      INJURIES   TO   THE  PERINEUM  AND   PELVIC  DIAPHRAGM 

accorded  to  the  bladder  by  the  fascia  between  the  latter  viscus 
and  the  vagina.  In  other  instances  the  posterior  vaginal  wall 
fails  to  hug  the  anterior  vaginal  wall  for  the  reason  given  above, 
i.e.,  injury  to  the  levator,  and  descent  of  the  bladder  is  inevitable 
whenever  intra-abdominal  pressure  is  increased  by  straining 
at  stool,  hfting,  or  reaching.  Once  the  protrusion  is  started 
it  tends  to  grow  larger  through  the  constant  stretching  and 
thinning  of  its  tissues,  and  after  the  menopause  atrophy  of  the 
muscles  accelerates  the  process.  As  the  bladder  is  attached 
firmly  to  the  cervix  throughout  its  supra-vaginal  portion,  the 
latter  is  drawn  anteriorly  beyond  its  normal  location  and 
eventually  follows  the  bladder  to  the  vulva,  while  the  fundus 
tips  posteriorly  as  a  consequence. 

At  first  the  symptoms  are  slight  and  may  consist  only  of 
some  bladder  irritability.  Later  there  is  a  feeling  of  loss  of 
support  and  dragging  in  the  pelvis,  with  difficulty  in  completely 
evacuating  the  bladder,  but  these  are  usually  ignored  until  the 
protruding  mass  attracts  the  patient's  attention.  Imperfect 
emptying. of  the  bladder  may  result  in  decomposition  of  the 
urine  and  cystitis,  and  the  impossibility  of  keeping  the  parts 
clean  leads  to  a  persistent  odor  of  decomposing  urine.  Ulcera- 
tion of  the  protruding  vaginal  wall  may  take  place  but  is  not 
so  common  as  ulceration  of  the  cervix  when  uterine  prolapse  is 
present. 

When  the  cystocele  is  of  moderate  size  no  protrusion  may  be 
apparent  with  the  patient  in  the  dorsal  position,  and  it  is  brought 
to  view  only  by  straining  efforts  during  which  more  and  more 
of  the  anterior  vaginal  wall  is  everted  through  the  vulvar  ring. 
Digital  examination  shows  partial  or  entire  absence  of  the 
strong  sling  of  levator  on  either  side  of  the  vagina,  and  if  further 
evidence  of  the  character  of  the  protrusion  is  needed  it  may  be 
secured  by  passing  a  sound  through  the  urethra  into  the  pro- 
lapsed bladder. 

The  treatment  is  anterior  colporrhaphy  and  perineorrhaphy 
as  described  on  pages  132  to  152. 


RECTOCELE 


125 


Rectocele,  or  protrusion  of  the  rectum  covered  by  the  pos- 
terior vaginal  wall,  is  frequently  but  not  necessarily  associated 
with  cystocele,  and  is  only  occasionally  found  alone.  The 
mechanism  of  its  production  is  similar  except  that  injury  to  the 


Fig.  42. — Secondary  results  of  injury  to  pelvic  diaphragm.  "Digital  exami- 
nation shows  partial  or  entire  absence  of  the  strong  sling  of  levator  on  either  side 
of  the  vagina." 


anterior  segment  of  the  pelvic  floor  is  not  a  necessary  antecedent. 
Posterior  displacement  of  the  anus  causes  the  fecal  mass 
to  impinge  upon  the  anterior  rectal  wall  during  defecation,  and 
thus  tends  to  drive  the  rectum  through  the  vulvar  orifice  which 


126      INJURIES   TO   THE  PERINEUM  AND   PELVIC  DIAPHRAGM 

is  itself  imperfectly  closed.  The  patient's  attention  may  be 
directed  to  this  by  difficulty  in  evacuating  the  bowels,  and  in 
extreme  cases  she  is  forced  to  hold  the  rectum  back  with  the 
fingers  in  the  vagina  before  it  can  be  emptied. 

The  nature  of  the  protrusion  is  evident  at  a  glance  but  may  be 
confirmed  by  rectal  examination  if  necessary. 


Fig.  43. — Repair  of  recent  small,  incomplete  perineal  laceration.     Sutures  passed 
from  skin  surface  but  penetrate  to  bottom  of  wound. 

Immediate  Repair  of  Perineal  Injuries. — Repair  of  all  in- 
juries to  the  pelvic  floor  should  be  made  at  once  unless  the 
tissues  are  in  such  condition  that  sloughing  is  to  be  expected, 
or  infection  has  certainly  taken  place.     By  immediate  repair 


IMMEDIATE   REPAIR 


127 


is  meant  repair  at  so  early  a  time  after  receipt  of  injury  that 
denudation  is  unnecessary,  usually  within  24  hours.  The 
object  sought  is  the  return  of  the  separated  tissues  to  their 
original  location,  not  the  concealment  of  injuries  by  cleverly 
placed  external  sutures.     Small  median  lacerations  are  sutured 


Fig.  44. — Repair  of  recent  small  incomplete  midline  laceration.  "If  the 
wound  extends  high  in  the  vagina  sutures  on  the  vaginal  surface  are  necessary." 
They  should  penetrate  to  the  bottom  of  the  wound. 


to  prevent  infection  and  more  extensive  injuries  to  secure  a 
return  to  normal  of  the  functions  of  the  involved  muscles. 

The  small  median  laceration  is  repaired  by  inserting  as  many 
sutures  from  the  skin  surface  as  may  be  required  to  secure 


128      INJURIES   TO   THE   PERINEUM  AND   PELVIC  DIAPHRAGM 

coaptation.  Usually  but  two  or  three  are  needed  for  this 
purpose  but  they  should  pass  to  the  bottom  of  the  wound.  If 
the  wound  extends  too  high  in  the  vagina  for  satisfactory 
closure  in  this  manner,  one  or  two  sutures  on  the  vaginal  surface 


Fig.  45. — Repair  of  recent  small  incomplete  midline  perineal  laceration, 
sutures  are  tied  and  approximate  depths  of  wound. 


Skin 


are  necessary.     If  the  stitches  are  passed  very  soon  after  de- 
livery no  anaesthetic  is  required. 

The  immediate  repair  of  complicated  lacerations,  those  ex- 
tending into  the  vaginal  sulci  or  passing  through  the  recto- 
vaginal septum,  should  be  viewed  as  a  distinct  surgical  operation 
to  be  carried  out  under  thorough  aseptic  precautions,  in  a  good 


COMPLICATED   LACERATIONS 


129 


light,  and  with  plenty  of  assistance.  An  anaesthetic  is  needed 
unless  the  patient  has  unusual  fortitude.  The  hurried  repair 
of  bad  perineal  tears  immediately  after  delivery,  and  while  the 
patient  and  attendant  are  both  exhausted,  needs  only  be  men- 
tioned to  be  condemned. 


Fig.  46. — Immediate  repair  of  small  complete  laceration.  The  deep  retention 
stitch  is  in  place  behind  the  sphincter  ends.  One  catgut  suture  is  laid  in  sphincter 
ends  for  greater  security. 


The  upper  portion  of  the  vagina  should  be  packed  with  sterile 

gauze  to  prevent  obscuring  of  the  field  by  blood  escaping  from 

the  uterus,  and  the  entire  injured  area  should  be  inspected 

thoroughly  with  the  labia  separated,  in  order  to  ascertain  the 

9 


130      INJURIES    TO    THE   PERINEUM  AND   PELVIC   DIAPHRAGM 

extent  and  character  of  the  damage.  The  first  suture  should  be 
placed  upon  the  vaginal  surface  beginning  at  the  apex  of  the 
wound  in  the  vagina.  Sometimes  it  is  impossible  to  reach  so 
high  with  the  first  stitch  and  in  that  event  one  may  be  placed  as 


Fig.  47, — Immediate  repair  of  small  complete  perineal  laceration.  The  deep 
retention  stitch  is  tied  and  knot  has  disappeared  in  anus.  Additional  catgut 
stitch  now  to  be  tied. 


high  as  possible  and  left  long,  when  traction  upon  its  ends  will 
expose  the  upper  portion  of  the  tear.  The  sutures  are  inter- 
rupted rather  than  continuous,  they  should  penetrate  to  the  bottom 
of  the  wound,  and  be  close  enough  together  to  approximate  the 


IMMEDIATE   REPAIR   OF   COMPLETE   LACERATION  I3I 

entire  surface.  The  last  vaginal  stitch  should  be  i  to  2  cm.  from 
the  external  surface,  after  which  the  remainder  of  the  laceration 
may  be  closed  by  sutures  passed  from  the  skin  side. 

Complete  lacerations  are  first  converted  into  incomplete  and 
then  sutured  as  above.  This  conversion  is  readily  accomplished, 
in  tears  which  do  not  extend  up  the  recto-vaginal  septum  but 
pass  through  the  sphincter  only,  by  the  introduction  of  one 
suture  which  enters  the  skin  well  behind  the  end  of  the  external 
sphincter  muscle  on  one  side,  emerges  on  the  raw  surface  above 
the  apex  of  the  wound  in  the  rectal  mucosa,  is  immediately  re- 
introduced, and  emerges  on  the  skin  surf  ace  &g/?m<i  the  other'end 
of  the  sphincter.  Traction  on  this  stitch  before  it  is  tied  shows 
that  the  ends  of  the  sphincter  are  brought  to  the  front  of  the 
rectum  where  they  belong,  and  usually  it  coapts  them  perfectly. 
For  the  sake  of  additional  security  one  or  two  catgut  sutures 
may  be  buried  in  the  apposed  ends  of  the  sphincter  muscle. 
After  the  bowel  is  closed  the  vaginal  injury  is  repaired  as  in  the 
incomplete  tear. 

If  the  recto-vaginal  septum  is  torn  well  above  the  sphincter, 
the  septum  is  first  repaired  by  suturing  the  rectal  mucosa  from 
above  downward.  The  stitches  thus  closing  the  septum  should 
be  introduced  from  the  rectal  side,  should  be  very  fine,  close 
together,  and  should  penetrate  the  rectal  mucosa  only.  This 
line  of  sutures  ends  just  above  the  sphincter  and  it  will  be  found 
that  the  injury  has  been  converted  into  the  type  above  de- 
scribed. The  deep  suture  behind  the  ends  of  the  retracted 
sphincter  now  completes  the  closure  of  the  bowel  and  there 
remains  the  ordinary  incomplete  laceration  to  be  closed  as 
before. 

Suture  Material. — Silk,  silkworm  gut,  silver  wire,  and  chromic 
catgut  may  all  be  successfully  used  in  repairing  perineal  in- 
juries, but  for  reasons  given  in  Chap.  XIX,  silkworm  gut  or  wire 
is  preferred  for  the  skin.  The  vaginal  sutures  are  best  made  of 
No.  I  or  No.  2  chromic  gut  to  obviate  the  necessity  for  distending 
the  vagina  during  their  removal,  and  the  rectal  sutures  arepref- 


132      INJURIES   TO   THE  PERINEUM  AND   PELVIC  DIAPHRAGM 

erably  made  with  silk  because  a  very  fine  needle  and  thread 
can  be  used  with  this  material.  The  smaller  the  perforation  in 
the  rectal  mucosa,  the  less  the  risk  of  deep  infection  of  the 
united  septum,  and  the  silk  suture  comes  away  spontaneously 
after  the  patient  has  recovered. 

THE  SECONDARY  REPAIR  OF  PERINEAL  INJURIES 

INCOMPLETE  LACERATION;  ANTERIOR  COLPORRHAPHY, 
PERINEORRHAPHY 

Anterior  colporrhaphy  is  usually  performed  at  the  same  sitting 
as  perineorrhaphy  because  injury  to  the  anterior  or  pubic  seg- 
ment of  the  perineum  is  so  frequently  found  in  association  with 
injury  to  the  posterior  or  perineal  segment.  Even  if  no  injury 
to  the  posterior  segment  has  occurred,  the  outlet  is  likely  to  have 
become  dilated  by  the  constant  wedge-hke  action  of  the  pro- 
lapsed bladder  when  the  anterior  segment  has  suffered  suffi- 
ciently to  permit  the  formation  of  a  cystocele. 

Many  anterior  colporrhaphies  have  been  devised  for  the  cure 
of  cystocele  but  the  really  valuable  ones  are  few.  A  defect 
which  is  common  to  many  is  superficial  denudation,  the  vaginal 
mucosa  only  being  removed,  while  the  efficient  operations  have 
two  factors  in  common:  (i)  Denudation  extends  to  the  bladder 
wall.  (2)  The  deep  structures  laterally  are  drawn  to  the 
median  line  and  so  sutured  that  the  fine  of  union  is  longitudinal, 
and  not  a  mere  pucker  on  the  anterior  vaginal  wall. 

After  drawing  down  the  cervix,  denudation  may  be  accom- 
plished by  one  of  two  methods:  (A)  The  area  of  anterior  vaginal 
wall  to  be  resected  is  outhned  by  scratching  with  a  sharp  knife, 
the  flap  so  outlined  seized  with  forceps  at  its  anterior  (^nd,  and 
the  incision  at  this  point  carried  through  the  thickness  of  the 
vaginal  wall.  The  bladder  is  then  wiped  from  the  vaginal  flap, 
the  incision  at  either  side  of  the  flap  prolonged  through  the 
vaginal  wall  so  far  as  the  separation  of  the  vagina  from  the 
bladder  has  proceeded,  the  bladder  wall  again  pushed  away, 


ANTERIOR  COLPORRHAPHY 


^33 


the  incision  again  extended,  until  the  flap  as  outlined  is  separated 
to  the  posterior  transverse  scratch,  when  this  is  cut  across  and 
the  flap  removed.  (B)  A  longitudinal  incision  is  made  from  the 
level  of  the  internal  urethral  orifice  to  the  cervico-vaginal 
junction.     This  incision  penetrates  through  the  vaginal  wall 


Fig.  48. — Anterior  colporrhaphy.  Method  A.  "The  area  to  be  resected  is 
outlined"  and  "the  flap  so  outlined  is  seized  with  forceps  at  its  anterior  end." 

to  the  bladder.  The  vaginal  tissue  on  either  side  of  this  in- 
cision is  seized  with  forceps  and  the  bladder  dissected  away  from 
it  with  the  finger  covered  with  gauze,  aided  occasionally  by  a 
snip  with  the  scissors.  If  the  proper  plane  is  reached  between 
the  bladder  and  vaginal  wall  this  may  be  accomplished  in  a 


134      INJURIES    TO    THE    PERINEUM   AND    PELVIC   DIAPHRAGM 

moment,  and  the  bladder  pushed  away  to  the  lateral  walls  of 
the  vagina  and  separated  both  anteriorly  and  posteriorly  to 
the  desired  extent.  No  tissue  is  removed  at  this  stage  of  the 
operation  when  method  B  is  followed. 


Fig.  49. — Anterior  colporrhaphy.     Method  B.     "A  longitudinal  incision  is  made 
from  the  level  of  the  external  urethral  orifice  to  the  cervico- vaginal  junction." 

If  method  A  has  been  followed  the  edges  of  the  cut  vaginal 
wall  are  united  longitudinally  with  interrupted  silkworm  gut 
or  continuous  chromic  catgut  sutures,  preferably  the  latter. 
If  method  B  has  been  adopted  a  continuous  chromic  catgut 
suture  is  introduced  at  one  end  of  the  wound  through  the  apex 
of  the  triangle  at  one  side,  carried  across  to  the  apex  of  the 


ANTERIOR   COLPORRHAPHY 


135 


triangle  on  the  opposite  side  and  tied,  after  which  it  is  continued 
in  a  similar  manner  to  the  other  end  of  the  wound,  the  needle 
picking  up  only  the  tissues  at  the  lateral  apex  of  the  wound  on 
each  side.     When  this  row  of  stitches  is  finished,  it  will  be  found 


M 

^ 

l^v 

M 

-^M 

"'-^'■fe^--              Tj^ 

■ 

m 

•    ^W 

j^  ''^L       m 

^ 

^ 

^ 

^^^ 

^' 

^Wm 

K#  : 

C^^^^^^ 

m. 

|l\^^ 

\^k. 

m 

^^ 

1^^,, 

'^ 

L^P^ 

\ 

^       \ 

"^^^^'^ilfc 

■HP/ 

V 

'  -A 

iiilP 

Fig.  50. — Anterior    colporrhaphy.     Method    B. 

wall  from  bladder. 


Separating    anterior    vagina 


that  the  vagina  is  firmly  narrowed  and  the  flaps  before  men- 
tioned fall  together  by  their  broad  raw  surfaces  instead  of  edge- 
wise. A  little  only  of  each  flap  is  snipped  off  with  the  scissors, 
so  that  a  distinct  column  is  left  down  the  middle  of  the  anterior 
vaginal  wall,  and  this  is  whipped  over  with  another  row  of 


136      INJURIES    TO    THE    PERINEUM  AND   PELVIC   DIAPHRAGM 

catgut  stitches.  By  this  method  much  less  tissue  is  removed 
than  by  method  A ,  and  that  which  remains  assists  in  thickening 
the  anterior  vaginal  wall. 


Fig.  51. — Method  B.     Suturing  cut  edges  of  vaginal  wall, 
first  closed  by  continuous  stitch. 


Deep  plane  of  fascia 


In  the  event  that  retrodisplacement  of  the  uterus  is  asso- 
ciated with  the  cystocele,  additional  denudation  and  suturing 
may  be  made  by  the  plan  proposed  by  Emmett.  At  the  cervical 
end  of  the  median  incision  two  lateral  areas  of  denudation  are 


ANTERIOR   COLPORRHAPHY 


137 


made  which  partially  surround  the  cervix.  These  areas  are 
extended  along  the  antero-lateral  vaginal  wall  at  the  cervico- 
vaginal  junction  in  such  a  manner  that  when  sutured  they 
pocket  the  cervix  and  tend  to  throw  it  back  toward  the  hollow 
of  the  sacrum. 


Fig.  52. — Anterior  colporrhapliy.     Method  B.     Sutures  adjusting  broad  edges 
of  flaps.     Suturing  is  best  done  from  behind  forward  contrary  to  illustration. 

Hirst  adds  to  the  usual  anterior  colporrhaphy  two  small  areas 
of  denudation,  one  at  either  side  of  the  urethra,  which  are  of 
undoubted  benefit.  These  are  triangular  in  shape,  the  base  of 
the  triangle  lying  at  the  vulva  while  the  apex  is  an  inch  higher 


138      INJURIES    TO    THE   PERINEUM   AND   PELVIC   DIAPHRAGM 

up  in  the  antero-lateral  vaginal  sulci.     These  are  so  closed  that 
the  line  of  sutures  runs  antero-posteriorly. 

Gersuny  of  Vienna  adjusts   a  purse   string   suture  in   the 


k\ 

A 

^ 

1 

If^^SmF. 

^^^.^^MMta 

^ 

jtt/MgtMm^f^r^ 

^^^  1^ 

^ 

1 

& 

^P 

■^ 

-      ^ 

--^^ 

fv 

yfSC. 

' 

f     ^ 

Fig.  53. — Anterior  colporrhaphy.     "Gersuny  of  Vienna  adjusts  a  purse-string 
suture  in  posterior  bladder  wall." 


posterior  bladder  wall  before  suturing  the  vagina,  so  that  the 
base  and  posterior  bladder  wall  are  projected  into  the  bladder  in 
the  form  of  a  cone. 


SECONDARY   PERINEORRHAPHY 


139 


Incomplete  Laceration,  Perineorrhaphy. — The  object  to  be 
obtained  by  secondary  perineorrhaphy  is  such  a  restoration  of 
the  posterior  segment  of  the  pelvic  floor  as  shall  enable  it  to 
perform  its  physiological  functions.  Restoration  to  its  original 
anatomical  condition  by  means  of  a  secondary  operation  is 
rarely  possible,  first,  because  the  ends  of  the  muscles  have  re- 


FiG.  54. — Anterior   colporrhaphy.     Method   B.     Purse   string   tied.     Suturing 
fascia  in  lateral  depths  of  wound. 

tracted,  and  second,  because  the  muscles  have  undergone 
atrophy  from  disuse.  This  applies  most  forcibly  of  course  to 
injuries  in  the  lateral  sulci.  Secondary  repair  of  small  median  in- 
juries is  of  no  surgical  importance  and  is  of  cosmetic  value  only. 
Three  distinct  types  of  operation  are  performed,  (ist)  That 
represented  by  the  Hegar  operation.     (2nd)  That  represented 


I40      INJURIES   TO   THE  PERINEUM  AND   PELVIC  DIAPHRAGM 

by  the  Emmett  operation.     (3rd)  That  represented  by  the  Tait 
or  flap-splitting  operation. 

The  Hegar  operation  and  its  modifications  depend  for  their 
efficiency  upon  a  large  area  of  denudation  and  the  consequent 
narrowing  of  the  vagina  which  is  produced  when  this  area  is 


Fig.  55. — Anterior  colporrhaphy.     Sagittal  section  after  completion  of  anterior 
colporrhaphy  with  addition  of  Gersuny's  purse-string  suture. 

sutured.     No  attempt  is  made  to  coapt   the  structures  ana- 
tomically. 

The  operation  is  performed  as  follows:  A  haemostat,  bullet 
forceps,  or  suture  is  made  to  grasp  the  tissue  at  each  side  of 


HEGAR  S   PERINEORRHAPHY 


141 


the  vulvar  orifice  at  the  level  of  the  uppermost  caruncle,  and  a 
third  catches  the  crest  of  the  rectocele  no  matter  how  high  in 
the  vagina  this  may  be.  Traction  laterally  is  then  made  on 
each  instrument  inserted  at  the  outlet,  while  the  one  on  the 


Fig.  56. — Hegar  operation  for  repair  of  incomplete  perineal  laceration.     Outline 

of  area  to  be  denuded. 


rectocele  is  drawn  anteriorly.  A  triangle  is  thus  exposed  which 
may  be  denuded  in  strips,  or  the  sides  of  the  triangle  may  be 
outlined  with  a  knife  and  the  entire  flap  dissected  off.     Sutures 


142       INJURIES    TO    THE   PERINEUM   AND   PELVIC   DIAPHRAGM 

are  inserted  from  side  to  side  beginning  at  the  apex  of  denuda- 
tion. When  the  raw  vaginal  surface  is  thus  closed,  external 
sutures  can  be  made  to  coapt  the  skin  perineum. 


P'iG.  57. — Ilegar  operation  for  incomplete  perineal  laceration.     The  denudation 
is  completed.     The  vaginal  sutures  have  been  inserted  from  side  to  side. 


The  Emmett  Operation. — In  this  operation  a  smaller  area 
is  denuded,  but  an  attempt  at  anatomical  repair  is  made  by 
following  the  original  lines  of  injury  in  the  vaginal  sulci. 

This  is  done  in  the  following  manner:  The  crest  of  the 
rectocele  together  with  the  highest  lateral  points  on  the  vaginal 
outlet,  which  are  expected  to  meet  in  the  new  perineum,  are 


emmett's  perineorrhaphy 


143 


seized  with  forceps  or  suture  as  in  the  Hegar  operation.  The 
instrument  on  one  side  of  the  vulvar  opening  is  drawn  directly 
outward,  while  the  one  on  the  crest  of  the  rectocele  is  drawn 
toward  the  outlet  and  to  the  opposite  side.     A  triangle  is  thus 


Fig.  58. — Emmett  operation  for  incomplete  perineal  laceration, 
indicate  area  to  be  denuded  in  one  sulcus. 


Dotted  lines 


formed  having  for  its  base  a  Hne  running  from  one  instrument 
to  the  other,  while  its  apex  is  indicated  by  the  upper  end  of  the 
scar  in  the  vaginal  sulcus  of  that  side.  When  the  instruments 
are  firmly  drawn  upon  tliis  triangle  has  an  obtuse  angle  at  its 
apex  and  is  readily  denuded  with  scissors.     Exactly  the  same 


144      INJURIES   TO   THE   PERINEUM  AND   PELVIC  DIAPHRAGM 

procedure  is  repeated  on  the  opposite  side.  Upon  releasing 
the  tension  upon  the  instrument  in  the  vagina  and  drawing 
each  of  those  upon  the  vulva  laterally,  a  third  triangle  of  unde- 
nuded  vagina  is  visible  whose  apex  is  at  the  level  of  the  vaginal 
instrument,  and  whose  base  line  extends  transversely  across  the 


Fig.  59. — Emmett  operation  for  incomplete  perineal  laceration.  Both  sulci 
and  third  triangle,  whose  base  is  at  mucocutaneous  junction,  have  been  denuded. 
Sulci  sutures  pass  obliquely  "so  that  the  bottom  of  the  stitch  is  nearer  the  vulva 
than  the  point  of  insertion." 

vulva  from  one  instrument  to  the  other  along  the  junction  of 
the  vaginal  mucosa  and  perineal  skin.  This  triangle  is  now 
denuded,  when  the  area  of  denudation  will  appear  as  in  Fig.  59, 
a  triangle  of  undenuded  vaginal  mucosa,  apex  downward,  ap- 
pearing superiorly  between  the  denuded  sulci. 

In  suturing,  the  lateral  sulci  are  closed  first,  the  particular 


EMMETT  S   PERINEORRHAPHY 


145 


part  of  the  Emmett  operation  most  often  overlooked  being  the 
direction  which  is  taken  by  the  needle.  This  is  not  inserted 
at  right  angles  to  the  posterior  vaginal  wall,  but  obliquely,  so 
that  the  bottom  of  the  stitch  is  nearer  the  vulva  than  the  point 
of  insertion,  the  effect  of  this  being  to  draw  the  tissue  between 
the  vagina  and  rectum  higher  into  the  vagina.     The  stitches 


Fig.  60. — Emmett  operation  for  incomplete  perineal  laceration.     Tiie  sulci  are 
closed,  excepting  the  lower  stitch  on  each  side.     Crown  stitch  laid  but  not  tied. 


should  also  be  buried  in  the  tissue  throughout  their  course,  as 
otherwise  the  mucosa  only  will  be  coapted  and  this  stretches 
out  in  time  and  allows  a  reproduction  of  the  old  relaxation. 
Suturing  of  the  sulci  is  continued  until  the  visible  portion  of 
denuded  surface  resembles  a  triangle  whose  apex  meets  the 
point  of  undenuded  mucosa  mentioned  above  as  the  crest  of  the 


10 


146      INJURIES   TO   THE   PERINEUM  AND   PELVIC  DIAPHRAGM 

rectocele,  the  base  of  the  triangle  being  the  line  of  junction  of 
perineal  skin  and  denuded  vaginal  wall. 

After  closure  of  the  sulci  the  so-called  crown  stitch  is  in- 
troduced with  a  large  well-curved  needle  which  enters  at  the 
point  occupied  by  the  forceps  at  one  side  of  the  vulva,  passes 


Fig.  61. — Emmett  operation  for  incomplete  perineal  laceration.     The  operation 

is  complete. 

transversely  across  buried  just  beneath  the  vaginal  mucosa, 
runs  through  the  tip  of  the  tongue  of  tissue  in  the  middle  of  the 
posterior  vaginal  wall,  and  emerges  on  the  opposite  side  at  the 
point  occupied  by  the  forceps  on  that  side.     This  suture  should 


SPLIT-FLAP   PERINEORRHAPHY 


147 


also  be  buried  throughout  its  entire  length,  and  when  tied  it 
approximates  the  points  formerly  occupied  by  the  three  forceps 
and  reveals  the  extent  of  skin  perineum  remaining  to  be  sutured. 
The  skin  sutures  are  then  introduced  from  side  to  side  and  the 
operation  is  completed. 


Fig.  62. — Secondary  repair   of  incomplete  perineal    laceration    by   split-flap 
method.     The  posterior  commissure  is  split  transversely. 

Split-flap  Perineorrhaphy.— As  originally  practised  by  Tait 
this  operation  had  little  more  than  a  cosmetic  effect,  but  on  its 
principle  is  based  an  operation  which  combines  the  advantages 


148      INJURIES    TO    THE   PERINEUM   AND    PELVIC   DIAPHRAGM 

of  the  Hegar  in  narrowing  the  vagina,  the  Emmett  in  elevating 
the  anus,  and  has  merits  of  its  own  in  securely  joining  the 
levators  of  either  side  between  the  vagina  and  rectum. 


I"iG.  63. — Secondary  repair  of  incomplete  perineal  laceration  by  split-flap 
method.  "The  vaginal  flap  is  raised  and  dissected  from  the  rectum  by  the  finger 
covered  with  gauze." 

Tait's  original  operation  consisted  in  separating  the  posterior 
vaginal  wall  from  the  skin  of  the  perineum  by  a  transverse 


SPLIT-FLAP   PERINEORRHAPHY 


149 


incision  made  with  scissors,  elevating  the  vaginal  flap,  deepening 
the  incision  to  the  extent  of  3  or  4  cm.,  and  uniting  the  wound  by 
sutures  placed  transversely.  The  flap  thus  elevated  was  not 
removed.  The  result  was  merely  to  unite  the  split  perineal 
body  whose  muscles  are  relatively  unimportant,  leaving  the 


Fig.  64. — Secondary  repair  of  incomplete  perineal  laceration  by  split-flap 
method.  Suture  catching  edge  of  levator.  Dotted  line  for  removal  of  super- 
fluous flap. 

true  supporting   structures  of  the  pelvic  floor  as  they  were 
before  operation. 

If,  however,  the  deep  dissection  is  carried  sufficiently  high 
between  the  rectum  and  vagina,  a  flap  is  raised  which  if  re- 
moved would  give  practically  a  Hegar  denudation,  and  if  the 


150      INJURIES    TO    THE   PERINEUM  AND    PELVIC   DIAPHRAGM 

dissection  is  carried  widely  enough  toward  the  lateral  vaginal 
walls  it  permits  of  the  adjustment  of  the  levator  muscle  and 
fascia  behind  the  vagina. 

After  placing  forceps  on  either  side  of  the  vulva  as  in  the 
preceding  operation,  the  posterior  commissure  is  spht  trans- 


FiG.  65. — Secondary  repair  of  incomplete  perineal  laceration  by  split-flap 
method.     Sutures  in  levators  not  tied.     Flap  in  process  of  removal. 

versely  from  one  forceps  to  the  other,  and  the  vaginal  flap  is 
raised  and  dissected  from  the  rectum  by  the  finger  covered 
with  gauze.  At  both  sides  some  cicatricial  tissue  may  need  to 
be  cut  with  scissors  but  the  dissection  as  a  whole  is  made  bluntly. 


SPLIT-FLAP   PERINEORRHAPHY 


151 


This  separation  may  be  continued  as  high  as  is  deemed  neces- 
sary, even  to  the  peritoneum,  and  should  extend  sufficiently  far 
laterally  to  expose  the  levators  to  view.  There  is  no  danger  of 
perforating  the  rectum  and  no  necessity  for  soiling  the  fingers 


Fig.  66. — Secondary  repair  of  incomplete  perineal  laceration  by  split-flap 
method.  The  edges  of  the  flap  have  been  approximated  after  t3dng  deep  sutures. 
The  skin  sutures  are  also  tied.     Operation  completed. 

by  their  introduction  into  the  anus.     An  occasional  large  vein 
which  is  torn  across  needs  tying. 

The  sutures  of  small  sized  chromic  catgut  are  started  at  the 
apex  of  the  denudation  and  approximate  the  lateral  vaginal  walls 


152      INJURIES    TO    THE   PERINEUM  AND   PELVIC   DIAPHRAGM 

posterior  to  the  flap  and  superior  to  the  levator  muscles.  The 
sutures  may  be  either  continuous  or  interrupted,  preferably  a 
combination  of  both  in  order  to  avoid  the  annoyance  of  a  broken 
strand  when  the  suture  is  nearing  completion,  so  necessitating 
re-suture  of  the  entire  wound  if  the  continuous  stitch  is  used 
without  interruption. 

When  the  levators  are  reached,  as  they  are  after  one  or  two 
stitches  are  in  place,  great  care  is  used  to  approximate  them 
broadly,  and  an  occasional  stitch  across  the  under  surface  of 
the  flap  serves  to  obliterate  dead  space  and  produce  a  column 
on  the  posterior  vaginal  wall.  When  the  sewing  has  reached  a 
point  near  the  skin,  catgut  is  discontinued  and  silkworm  gut 
used  on  the  external  surface.  Before  closing  the  skin  the  small 
portion  of  superfluous  flap  which  is  found  projecting  above  the 
closed  wound  is  trimmed  off,  and  the  edges  united  to  each  other 
and  to  the  external  skin.  Some  operators  allow  the  superfluous 
portion  of  flap  to  remain,  but  this  leaves  a  tag  of  tissue  which 
projects  from  the  vagina  after  heaHng  is  complete.  While  this 
is  of  no  practical  importance  the  work  looks  unfinished  and  it 
sometimes  alarms  the  patient  when  it  is  discovered. 

Complete  Laceration. — Secondary  repair  of  complete  lacera- 
tion is  becoming  less  frequent  since  such  injuries  now  are  rarely 
overlooked  at  the  time  of  their  occurrence,  and  primary  repair 
is  generally  successful.  The  few  cases  in  which  repair  has  not 
been  attempted  or  in  which  union  has  failed  are  left  in  a  very 
annoying  condition  because  of  incontinence  of  gas  and  liquid 
feces.  When  the  injury  extends  barely  through  the  sphincter, 
enough  scar  tissue  may  form  across  the  anterior  wall  of  the  anus 
to  give  partial  control,  but  spontaneous  union  of  the  anterior 
ends  of  the  sphincter  is  rendered  impossible  by  reason  of  their 
wide  retraction. 

Owing  to  the  previously  mentioned  fact  that  complete  tears 
are  central  and  do  not  involve  the  levator  muscles  or  fascia,  the 
anus  is  held  well  forward  and  no  prolapse  of  the  viscera  is  present. 

Examination  at  once  reveals  the  condition.     The  edge  of  the 


PERINEORRHAPHY   FOR   COMPLETE    LACERATION  1 53 

recto-vaginal  septum  is  thin  and  the  rectal  mucosa  is  visible 
posteriorly.  At  either  side  of  the  anus,  but  on  a  line  with  its 
posterior  margin,  a  small  pit  or  dimple  reveals  the  location  of 
the  sphincter  ends. 

Simple  Operation. — The  principal  object  to  be  sought  in  the 
repair  of  complete  laceration  is  the  restoration  of  the  integrity 
of  the  rectum  and  anal  sphincter,  and  the  simplest  method  of 
attaining  this  object  is  to  denude  the  area  covered  by  cicatricial 
tissue — taking  pains  to  make  the  denudation  as  broad  as  possible 
at  its  apex — to  suture  the  rectal  mucosa  from  the  rectal  side, 
being  especially  careful  of  the  first  stitch  at  the  apex,  and  to 
insert  one  or  two  tension  sutures  behind  the  sphincter  ends. 
The  injury  is  thus  converted  into  an  incomplete  laceration  which 
is  repaired  by  suturing  the  vaginal  mucosa  from  the  vaginal 
surface  and  completing  the  operation  by  stitching  the  skin 
perineum. 

Owing  to  the  difficulty  of  accurately  placing  the  sutures, 
through  leakage  along  the  rectal  wall,  and  the  mechanical 
result  of  bowel  movements,  union  unfortunately  fails  here  more 
often  than  in  incomplete  injuries,  and  methods  of  repair  which 
remove  no  tissue  are  preferable  to  the  one  outlined.  These 
methods  are  all  based  on  the  flap-splitting  principle  and 
are  sufficiently  represented  by  the  following,  which  is  entirely 
satisfactory. 

SPLIT-FLAP  OPERATION 

With  a  sharp  knife  the  margin  of  the  recto-vaginal  septum  is 
first  spHt  transversely  to  a  depth  of  at  least  i  cm.  This  pro- 
vides a  vaginal  flap  and  a  rectal  flap  at  the  apex  of  the  tear. 
Each  end  of  this  incision  is  then  prolonged  through  the  scar 
tissue  along  the  lateral  vaginal  wall  on  either  side  of  the  cloaca 
and  at  least  }/2  cm.  from  the  rectal  mucosa,  the  incision  termi- 
nating at  the  skin  on  either  side.  The  first  incision  is  thus  com- 
pleted as  an  inverted  U,  the  convex  end  of  which  is  situated  in 


154      INJURIES    TO   THE   PERINEUM  AND   PELVIC   DIAPHRAGM 

the  recto- vaginal  septum  above,  the  legs  of  the  U  extending 
through  the  scar  at  either  side  to  the  skin. 

From  each  end  of  this  incision,  that  is  at  the  junction  of 
vaginal  mucosa  and  skin  and  at  right  angles  to  it,  a  short  antero- 
posterior cut  is  made.     The  anterior  end  of  this  last  incision  is 


Fig.  67. — Secondary  repair  of  complete  laceration  of  perineum. 
Line  of  incisions. 


on  a  level  with  the  remnant  of  the  lower  hymeneal  caruncle. 
The  posterior  end  extends  just  through  the  dimple  representing 
the  retracted  end  of  the  sphincter  ani. 

Reference  to  the  figure  will  show  that  two  flaps  are  now  out- 


PERINEORRHAPHY   FOR   COMPLETE    LACERATION 


:>D 


lined  upon  either  side.  By  dissecting  up  each  anterior  flap  to 
the  extent  to  which  it  is  covered  by  cicatrix,  tissue  for  the  new 
posterior  vaginal  wall  is  furnished.  By  dissecting  and  turning 
backward  the  posterior  flaps  to  the  extent  to  which  they  are 


Fig.  68. — Secondary  repair  of  complete  perineal  laceration.     Flaps  have  been 
raised  anteriorly  and  posteriorly  by  blunt  dissection  with  finger. 


covered  by  cicatrix,  sufficient  raw  surface  is  exposed  to  hold  the 
sutures  which  are  to  approximate  the  anterior  rectal  wall,  and 
the  retracted  sphincter  ends  are  uncovered.  Exposure  of  these 
sphincter  ends  must  be  complete. 

Suturing  may  now  begin.     For  the  rectal  stitches  fine  silk  or 


156      INJURIES    TO   THE   PERINEUM  AND    PELVIC   DIAPHRAGM 

celloidin  thread  is  preferable.  The  first  stitch  is  taken  at  the 
very  apex  of  the  tear,  the  needle  penetrating  the  rectal  mucosa 
only.  This  stitch  is  at  once  tied  with  the  knot  on  the  rectal 
side,  and  then  continued  to  the  anal  skin  as  a  continuous  close 


Fig.  69. — Secondary  repair  of  complete  perineal  laceration.  Continuous 
rectal  suture  in  position  but  not  drawn  up.  Deep  retention  suture  laid  through 
sphincter  ends. 

set  suture.  It  is  not  always  feasible  to  finish  and  tighten  the 
lowermost  end  of  this  suture  until  a  retention  suture  for  the 
sphincter  is  placed.  This  should  be  of  rather  coarse  silkworm 
gut  and  is  introduced  behind,  not  through,  the  ends  of  the  sphinc- 


PERINEORRHAPHY   FOR   COMPLETE    LACERATION 


157 


ter  and  passes  high  up  toward  the  apex  of  the  wound  as  de- 
scribed on  page  131.  When  drawn  upon  this  suture  approxi- 
mates the  ends  of  the  sphincter,  and  the  continuous  rectal  suture 
is  tied  while  the  retention  suture  is  held.  The  latter  is  then 
tied  and  cut  and  the  ends  at  once  retract  inside  the  anus.     If 


Fig.  70. — Secondary  repair  of  complete  perineal  laceration. 

drawn  up. 


Rectal  suture 


deemed  necessary  one  or  two  fine  buried  catgut  stitches  may  be 
applied  in  order  more  closely  to  unite  the  sphincter  ends. 

The  tear  now  has  been  converted  into  the  incomplete  form 
and  the  final  repair  is  made  by  suturing  the  vaginal  side  of  the 
recto-vaginal  septum  and  the  skin  surface. 


158      INJURIES   TO   THE  PERINEUM  AND   PELVIC  DIAPHRAGM 

General  Remarks.^ — Though  operations  upon  the  female 
perineum  are  performed  in  an  area  which  is  never  completely 
or  even  adequately  sterihzable,  they  are  almost  uniformly 
successful  if  properly  performed.  Preliminary  asepsis  neverthe- 
less should  be  as  perfect  as  possible.  Large  preliminary  douches, 
made   soapy   with    green    soap,    creolin    or    lysol    should    be 


Fig.  71. — Secondary  repair  of  complete  perineal  laceration.  Rectal  mucosa 
approximated.  Knot  of  retention  suture  has  disappeared  within  anus.  Tear 
is  now  incomplete.  Sutures  in  vaginal  flap  for  restoration  of  posterior  vaginal 
wall. 


used  for  a  day  or  two  preceding  operation,  not  so  much  for  their 
antiseptic  effect  as  their  mechanical  cleansing  qualities.  The 
lower  bowel  should  always  be  empty,  else  the  operative  area 
will  certainly  be  soiled  by  fecal  matter  during  the  operation. 
This  condition  should  be  secured  by  a  laxative  24  hours  before 
operation,  an  enema  immediately  after  the  laxative  has  acted, 


PERINEORRHAPHY 


159 


and  another  four  or  five  hours  before  the  operation.  The 
external  parts  should  be  prepared  after  the  patient  is  anaes- 
thetized in  order  that  it  may  be  done  thoroughly.  In  the  repair 
of  incomplete  laceration  the  finger  should  not  be  introduced  into 
the  rectum. 


Fig.  72. — Secondary  repair  of  complete  perineal  laceration.     Posterior  vaginal 
wall  restored.     Skin  sutures  tied.     Repair  is  complete. 

The  utmost  neatness  should  be  observed  in  the  repair  of  com- 
plete injuries,  and  all  gloves,  instruments,  etc.,  changed  after  the 
rectum  is  closed. 

Even  with  the  greatest  care  some  contamination  is  inevitable 


l6o      INJURIES   TO   THE  PERINEUM  AND   PELVIC  DIAPHRAGM 

and  one  is  forced  to  the  conclusion  that  this  portion  of  the  body 
is  at  least  partially  protected,  and  that  its  resistance  toward  its 
own  type  of  infection  is  increased  by  the  constant  soiling  to 
which  it  is  subjected  throughout  Hfe. 

While  the  suturing  should  be  accurate  throughout  and  the 
tissue  approximated,  the  stitches  should  not  be  tight,  else  they 
will  cut  and  sink  into  the  parts  so  deeply  that  their  removal  is 
difficult. 

After-care. — An  iodoform  gauze  strip  is  lightly  packed  into 
the  vagina  at  the  close  of  the  operation  to  act  as  a  capillary  drain 
for  the  first  two  days,  at  the  expiration  of  which  time  it  may  be 
removed.  Douches  are  not  used  unless  the  discharge  is  free, 
and  they  are  best  avoided  for  a  week  at  least,  since  the  mechan- 
ical disturbance  of  the  parts  more  than  offsets  the  problematical 
good  which  they  do.  No  attempt  is  made  to  keep  the  perineum 
dry  as  the  mechanical  disturbance  of  wiping  does  more  harm 
than  good,  and  in  any  event  dryness  cannot  be  secured.  The 
catheter  is  not  used  unless  absolutely  necessary  as  fresh  urine 
is  sterile,  but  the  external  parts  are  douched  with  sterile  water 
after  each  urination  and  defecation. 

The  care  of  the  bowels  after  repair  of  an  incomplete  tear  is  that 
after  any  operative  procedure,  but  after  the  repair  of  complete 
injury  much  thought  must  be  given  to  their  condition.  One  is 
confronted  by  the  necessity  for  avoiding  hard  scybalae  or  large 
bowel  passages  on  the  one  hand,  and  the  desirability  of  keeping 
the  wound  clean  on  the  other.  For  reasons  given  above,  me- 
chanical injury  seems  more  fatal  to  healing  than  does  soiling, 
and  it  has  become  the  author's  routine  practice  to  limit  the  diet 
to  liquids,  excluding  milk,  for  two  days,  and  then  to  open  the 
bowels  by  means  of  small  repeated  doses  of  one  of  the  saHne 
laxatives.  So  soon  as  the  bowels  show  an  inclination  to  move 
an  oil  enema  is  given  through  a  soft  rubber  catheter,  and  the 
external  wound  is  thoroughly  douched  after  the  evacuation  is 
complete.  After  the  first  motion  the  severe  dietary  restriction 
is  somewhat  relaxed,  but  bulky  food  and  milk  are  avoided  and  a 


REFERENCES  l6l 

soft  bowel  motion  secured  every  second  day.  The  stitches  are 
removed  from  the  external  surface  in  from  9  to  1 2  days,  the  cat- 
gut vaginal  sutures  do  not  need  removal,  and  the  celloidin  or 
silk  rectal  suture  comes  away  spontaneously.  The  patient  may 
be  up  at  the  expiration  of  12  or  14  days  after  operation  for  com- 
plete laceration,  but  the  recumbent  posture  is  desirable  for  a 
few  days  longer  in  cases  in  which  there  has  been  a  marked  cysto- 
cele,  rectocele,  or  uterine  prolapse. 

The  legs  are  not  bound  together  unless  the  patient  is  very  ex- 
citable as  no  ordinary  motion  of  the  extremities  puts  any  strain 
upon  the  suture  line. 

REFERENCES 

EDGAR. — Etiology  of  Perineal  Lacerations.  N.  York  Med.  J.,  1912,  xcv,  781. 
SCHATZ.— Ueber  die  Zerreissungen   des   muskulosen    Beckenbodens   bei  der 

Geburt.     Arch.f.  Gyn.,  1884,  xxii,  298. 
DICKINSON. — Primary   Perineorrhaphy  by   Buried   and  Sub-surface  Catgut 

Suture.     N.  York  M.  J.,  1914,  c,  157. 
McDonald. — ^Laceration  of  the  Perineum,  Etc.     Surg.,  Gyn.  b'  Obst.,  1908,  vi, 

47- 
GRANT,  BALDWIN.— The  Cure  of  Prolapse  of  the  Uterus  and  Bladder  by 

Plastic  Operation.     N.  York  M.  J.,  191 2,  xcvi,  952. 
STURMDORF.— Perineorrhaphy    in    Principle  and    Pracrice.     Am.    J.  Obst., 

1912,  Ixvi,  382. 
GOLDSPOHN. — Fundamental    Intrapelvic    Perineorrhaphy.     /.    A.    M.   A., 

1914,  Ixiii,  538. 
DORSETT. — A  Simple  Operation  for  Repair  of  the  Female  Perineum,  Based  on 

the  Anatomy  of  the  Parts.     J.  A.  M.  A.,  191 2,  lix,  1182. 
EMMETT. — Study  of  the  Etiology  of  Perineal  Laceration  wdth  a  New  Method 

for  Its  Proper  Repair.     Trans.  Am.  Gyn.  Soc,  1883,  viii,  198. 
JELLETT. — Suture  of  the  Levator  Ani  Muscle  in  Perineorrhaphy  Operations. 

Lancet,  1914,  ii,  315;  Surg.,  Gyn.  b°  Obst.,  1914,  xix,  346. 
MARTIN. — Zur  Anatomie  und  Technik  der  Levator-Fasciennaht.     Arch.  /. 

Gyn.,  1912,  xcvii,  301. 
WATKINS. — Perineorrhaphy  for   Complete  Laceration.     Surg.,  Gyn.  b'  Obst., 

1908,  vii,  I. 
ILL. — Secondary  Repair  of  Complete  Perineal  Lacerations;  Its  Technique  and 

Results.     Tr.  Am.  Assn.  Obst.  df  Gyn.,  191 1,  xxiii,  287;  Am.  J.  Obst.,  191 1, 

Ixiii,  118. 
BANGA. — Tait's  Operation  for  Complete  Laceration  of  the  Perineum.     Snrg. 

Gyn.  &°  Obst.,  1909,  ix,  351. 

II 


1 62      INJURIES    TO    THE   PERINEUM   AND   PELVIC   DIAPHRAGM 

TAIT,  L. — On  New  Methods  of  Operation  for  Repair  of  the  Female  Perineum. 

Tr.  Obst.  Soc.  Lond.,  1879,  xxi,  292. 
KELLY. — The  Dissection  and  Liberation  of  the  Sphincter  Ani  Muscle  Followed 

by  Its  Direct  Suture  in  Cases  of  Complete  Tear  of  the  Perineum,  Etc.     Bull. 

Johns  Hopkins  Hosp.,  x,  i. 


CHAPTER  VI 

DISEASES  AND  INJURIES  OF  THE  VAGINA 

Vaginitis. — Clinically,  vaginitis  is  divided  into  the  acute  and 
chronic  forms  according  to  the  symptoms  presented  and  the 
duration  of  the  disease.  Here,  as  elsewhere  on  epithehal  sur- 
faces, a  strict  differentiation  between  acute  and  chronic  inflam- 
mation on  pathological  grounds  cannot  be  made,  as  true  chronic 
inflammation  characterized  by  the  formation  of  new  connective 
tissue  is  rarely  found. 

Acute  vaginitis  may  be  caused  by  traumatism,  by  chemical 
damage,  and  by  infection.  Injury  eventuating  in  inflammation 
may  be  produced  by  violent  or  frequent  coitus  and  by  foreign 
bodies  such  as  ill-fitting  pessaries.  Inflammation  caused  by 
chemical  agents  is  exemplified  by  the  vaginitis  which  follows 
the  use  of  strong  bichloride  of  mercury  douches  for  the  preven- 
tion of  conception,  imperfect  solutions  of  carboHc  acid  used  for 
cleansing  purposes  in  which  the  pure  acid  comes  into  contact 
with  the  vaginal  mucosa,  and  douches  of  powerful  astringents. 
In  adults,  vaginitis  of  gonorrheal  origin  as  well  as  that  asso- 
ciated with  cancer  of  the  uterus  is  probably  due  to  chemical 
irritation  of  the  discharge  rather  than  direct  microbic  action. 

Acute  vaginitis  due  to  infection  is  produced  by  divers  patho- 
genic micro-organisms. 

Streptococci,  staphylococci,  colon  bacilH,  and  diphtheria 
bacilH  may  invade  the  vagina  and  set  up  inflammatory  action. 
While  the  first  three  mentioned  are  many  times  present  in  the 
vagina  without  invading  the  tissues,  they  are  the  common  source 
of  infectious  vaginitis  following  the  injuries  produced  by  child 
birth. 

As  stated  above,  gonorrheal  vaginitis  is  more  hkely  due  to 
the  chemical  irritation  of  pus  from  an  infected  cervix  than  to 

163 


164  DISEASES   AND   INJURIES   OF   THE  VAGINA 

the  direct  invasion  of  the  vaginal  mucosa  by  gonococci,  but 
in  infants  and  very  young  children  the  character  of  the  vaginal 
covering  more  nearly  resembles  that  of  a  true  mucous  membrane 
and  a  gonococcus  infection  of  the  vagina  may  occur. 

Some  cases  of  vaginitis  appear  to  be  due  to  trophic  disturb- 
ances only.  Thus  we  have  the  papillary  vaginitis  of  pregnancy 
without  actual  bacterial  invasion,  and  senile  vaginitis  some- 
times seems  to  be  entirely  trophic  in  its  nature. 

Symptoms. — The  local  symptoms  of  acute  vaginitis  are  burn- 
ing, throbbing,  and  pain.  In  severe  infections  the  general 
symptoms  are  marked,  but  in  ordinary  instances  of  acute 
vaginitis  there  is  no  elevation  of  temperature  or  increase  in  the 
pulse  rate. 

The  physical  signs  are  redness  and  increased  local  temperature, 
followed  in  a  short  time  by  a  marked  increase  in  the  vaginal 
secretion.  Areas  which  are  partially  denuded  of  epithelium 
bleed  readily,  and  thus  the  secretions  may  be  blood  stained.  In 
the  papillary  vaginitis  of  pregnancy  the  vagina  is  studded  with 
minute,  reddish  looking,  granular  elevations.  In  senile  vaginitis 
the  mucosa  appears  atrophic  but  with  red  patches  which  are 
smooth  and  bleed  readily.  In  puerperal  vaginitis  membranous 
deposits  are  not  uncommon. 

Treatment. — In  very  acute  cases,  whether  puerperal  or  other- 
wise, the  patient  should  remain  in  bed. 

In  puerperal  vaginitis  douches  should  not  be  given  because 
of  the  risk  of  infecting  the  uterus.  Ulcerated  areas  should  be 
touched  with  pure  carbolic  to  be  neutraHzed  immediately  by 
alcohol,  or  a  very  strong  solution  (10-20  per  cent.)  of  nitrate 
of  silver  may  be  apphed  to  the  ulcer. 

Abundant  drainage  may  be  secured  by  a  loose  packing  of 
iodoform  gauze  in  the  vagina.  If  the  infecting  agent  is  the 
Klebs-Loefller  bacillus,  diphtheria  antitoxin  must  be  given,  but 
membrane  on  the  vaginal  wall  may  be  due  to  streptococcic  in- 
fection instead  of  true  diphtheria. 

Ordinary  acute  vaginitis  is  readily  controlled  by  the  use 


TREATMENT   OF  VAGINITIS 


i6S 


of  abundant  warm  normal  salt  or  boric  acid  douches  in  the 
early  stages,  followed  by  astringent  injections  as  the  acute 
symptoms  subside  and  the  discharge  becomes  free.  After  the 
primary  irritation  has  subsided,  the  vagina  should  be  thoroughly 


Fig.  73. — Vaginal  cyst. 

mopped  out  once  a  week  with  a  moderately  strong  solution  of 
silver  nitrate,  or  the  silver  solution  may  be  poured  in  through  a 
cylindrical  speculum.  Should  this  give  rise  to  pain  it  may  be 
neutralized  at  once  with  salt  solution.     Some  of  the  milder 


1 66  DISEASES   AND   INJURIES   OF  THE  VAGINA 

silver  salts,  such  as  Argyrol  and  Protargol,  may  be  used  from  the 
outset  without  causing  irritation,  but  nothing  equals  the  nitrate 
in  efficiency  after  the  early  pain  and  swelling  have  disappeared. 

The  vaginitis  of  pregnancy  may  be  treated  in  the  same  man- 
ner, but  solutions  should  always  be  weaker  than  those  used  in  the 
non-pregnant,  and  the  risk  of  inducing  abortion  by  prolonged 
hot  douches  must  be  borne  in  mind. 

In  the  gonorrheal  vaginitis  of  infants  the  vagina  should  be 
irrigated  frequently,  using  a  small  soft  rubber  catheter  in  order 
to  avoid  injury  to  the  hymen,  and  weekly  or  semi-weekly  in- 
stallations of  silver  solution  are  to  be  applied  by  the  physician 
with  a  small  medicine  dropper. 

Senile  vaginitis  is  intractable  to  treatment.  Here  the  milder 
alkahne  douches  such  as  biborate  or  bicarbonate  of  sodium  are 
serviceable,  but  a  permanent  cure  is  rarely  effected. 

Tumors. — New  growths  of  the  vagina  are  relatively 
uncommon. 

Carcinoma  of  the  vault  is  occasionally  found  and  should  be 
extirpated  if  complete,  far-reaching  removal  is  possible.  It  is 
not  often  that  a  sufficiently  wide  removal  can  be  practised  to 
make  operation  justifiable,  and  incomplete  removal  or  curettage 
is  more  likely  to  cause  wide  dissemination  than  to  effect  a  cure. 
While  a  well- developed  cancer  of  the  vaginal  vault  is  almost 
hopeless,  the  X-ray  and  radium,  or  the  actual  cautery  as  ad- 
vised for  cancer  of  the  cervix,  should  always  be  tried. 

Vaginal  cysts  are  occasionally  seen  and  may  reach  a  large 
size.  They  are  presumed  to  have  their  origin  in  unobliterated 
portions  of  Gaertner's  duct  and  may  extend  deeply  into  the 
para-vaginal  structures  at  the  lateral  vaginal  fornices.  Extir- 
pation may  be  difficult  and  bloody,  and  if  it  becomes  apparent 
that  complete  removal  is  too  formidable  the  cyst  should  be 
incised,  as  much  of  its  wall  removed  as  possible,  and  the  cavity 
forced  to  heal  from  the  bottom  by  constant  gauze  packing. 

Injuries. — Injuries  to  the  vagina  may  be  produced  by  violence 
or  the  introduction  of  foreign  bodies,  and  are  to  be  treated  on 


VESICO-VAGINAL    AND    RECTO-VAGINAL    FISTUL^E 


167 


general  surgical  principles  by  suture,  drainage  when  indicated, 
etc. 

Puerperal  injuries  due  to  laceration  or  cutting  with  forceps 
blades  need  no  special  comment  as  they  are  repaired  in  con- 
nection with  repair  of  the  injuries  to  the  vaginal  outlet  with 
which  they  are  associated. 

VESICO-VAGINAL   AND   RECTO-VAGINAL  FISTULA 

Puerperal  injuries  due  to  sloughing,  however,  are  of  quite 
another  type,  and  it  was  in  an  effort  to  cure  these  that  J.  Marion 
Sims  laid  the  foundation  of  modern  gynaecology. 


Fig.  74. — Remote  result  of  sloughing  of  recto-vaginal  septum.     Recto-vaginal 

fistula. 


Lacerations  through  the  vaginal  wall  extending  into  the 
bladder  usually  heal  even  if  unrepaired,  and  similar  injuries  ex- 
tending into  the  rectum  sometimes  follow  the  same  course,  but 
sloughing  and  loss  of  tissue  render  healing  impossible  in  the 
event  that  either  bladder  or  rectum  are  involved.  It  follows, 
therefore,  that  vesico-vaginal  and  recto-vaginal  fistulae  occur- 


1 68 


DISEASES   AND  INJURIES   OF   THE  VAGINA 


ring  at  the  time  of  labor  may  heal  without  intervention,  but  such 
fistulae  are  Hkely  to  remain  permanent  if  they  have  their  incep- 
tion several  days  later,  when  they  are  due  to  necrosis  and 
sloughing. 

The  etiology  of  both  vesico-vaginal  and  recto-vaginal  fistulae 
is  the  same;  sloughing  brought  about  by  pressure  necrosis  due 
to  great  prolongation  of  the  second  stage  of  labor.  While  this 
was  a  common  accident  when  the  obstetric  forceps  was  used 
only  as  a  last  resort,  it  is  rarely  seen  at  the  present  time  when 


Fig.  75. — Remote  result  of  sloughing  of  vesico-vaginal  septum.     Vesico-vaginal 

fistula. 


the  same  instrument  is  too  frequently  used  without  the  slightest 
justification. 

Symptoms. — The  symptoms  are  plain;  escape  of  urine  through 
the  vagina  in  vesico-vaginal  fistulae,  and  escape  of  gas  or  feces 
or  both,  in  recto-vaginal  fistulae.  On  examination  the  lesion 
is  readily  discovered  if  the  loss  of  tissue  has  been  large,  but  in 
small  leaks  the  injection  of  colored  fluid  into  the  involved  viscus 
may  be  necessary  before  the  opening  can  be  found. 

Vaginitis  is  set  up  by  the  irritation  of  the  excretions  passing 
through  the  vagina,  and  in  vesical  fistula  the  deposition  of 


VESICQ-VAGINAL  FISTULA  1 69 

urinary  salts  upon  the  vagina  and  vulva  is  usual.  Recto- 
vaginal fistulae,  as  a  rule,  are  moderate  in  size  because  the  pos- 
terior vaginal  and  anterior  rectal  walls  do  not  suffer  so  severely 
from  prolonged  pressure  as  do  the  anterior  vaginal  and  vesical 
walls. 

Vesico-vaginal  fistulas  are  sometimes  very  extensive,  involving 
the  entire  vesico-vaginal  septum  and  extending  into  one  or 
both  ureters,  and  occasionally  the  anterior  uterine  wall  is  also 
destroyed  converting  the  bladder,  uterine  cavity,  and  vagina 
into  one  large  cloaca. 

Treatment. — Very  small  openings  into  either  bladder  or  rec- 
tum frequently  heal  through  the  cicatricial  contraction  follow- 
ing the  cautious  and  gentle  application  of  the  thermo-cautery. 
In  all  other  instances  the  treatment  is  operative. 

Operations  for  Vesico-vaginal  Fistula. — Before  operating,  the 
vaginitis  which  is  present  should  be  relieved  by  mechanical 
removal  of  the  deposit  of  urinary  salts,  followed  by  douches 
and  astringent  applications.  The  re-accumulation  of  these  de- 
posits can  be  prevented  to  some  extent  by  the  administration 
of  ammonium  or  sodium  benzoate  in  io-15-grain  doses  three  or 
four  times  daily.  These  compounds  of  benzoic  acid  tend  to 
render  the  urine  acid  and  thus  prevent  precipitation  of  the 
triple  phosphates  of  which  the  concretions  are  composed. 

In  the  very  small  fistulae  the  operation  is  simple  and  consists 
in  denudation  of  the  edges  of  the  opening  and  their  approxi- 
mation by  suture  in  the  direction  of  least  resistance.  The 
opening  can  usually  be  exposed  by  firm  retraction  of  the  per- 
ineum while  the  patient  is  in  the  lithotomy  position,  but  the 
latero-prone  or  Sims^s  position  may  be  required.  The  denuda- 
tion should  be  made  in  such  a  manner  that  its  broad  face  is 
upon  the  vaginal  wall,  and  sutures,  if  in  one  layer,  should  pene- 
trate, to  but  not  through,  the  bladder  mucosa. 

The  sutures  should  be  of  silkworm  gut  or  silver  wire  and 
should  be  just  tight  enough  to  approximate  the  tissues  without 
tension.     ^^  Tension  is  fatal  to  success  in  plastic  surgery  J^ 


lyo 


DISEASES   AND   INJURIES    OF   THE  VAGINA 


In  the  after-treatment  the  bladder  is  kept  empty  by  the 
introduction  of  a  permanent  or  retention  catheter  until  heahng 
is  complete,  as  this  is  less  hkely  to  produce  cystitis  than  repeated 
catheterization. 

Large  openings,  or  moderate-sized  openings  whose  edges 
cannot  readily  be  approximated,  demand  a  more  extensive 
operation,  and  separate  suture  of  the  bladder  and  vaginal  walls. 


Fig,  76. — Sutures  inserted  for  repair  of  vesico-vaginal  fistula.     Note:  No  sutures 

in  bladder  mucosa. 


Placing  the  patient  in  that  position,  usually  the  Sims's,  by 
which  the  fistula  is  most  completely  exposed,  its  margins  are 
split,  separating  the  bladder  from  the  anterior  vaginal  wall. 
Once  the  line  of  cleavage  is  found,  it  is  comparatively  easy  to 
carry  this  separation  to  the  lateral  vaginal  walls  if  necessary 
in  order  that  the  bladder  margins  may  come  together  easily. 
Buried  sutures  of  fine  chromic  gut  then  unite  the  sides  of  the 


VESICO-VAGINAL  FISTULA 


171 


opening  into  the  bladder,  these  sutures  taking  in  bladder  wall 
only  and  being  applied  Lembert  fashion,  turning  up  a  ridge 
into  the  interior  of  the  organ.  The  vaginal  wall  is  next  repaired, 
using  silkworm  gut  or  silver  wire,  and  if  possible  leaving  a  ridge 
in  the  vagina.  In  this  manner  the  sutures  approximate  a  far 
larger  area  of  raw  surface  than  is  possible  if  the  edges  only  are 
united,  with  a  correspondingly  greater  chance  that  firm  healing 
will  occur. 


Fig.  77. — Sagittal  section  after  sutures  are  tied.     Note:  Bladder  mucosa  falling 

together  without  suture. 


Complete  destruction  of  the  vesico-vaginal  septum  is  ex- 
tremely difficult  to  repair.  The  method  most  likely  to  succeed 
involves  opening  the  bladder  through  a  supra-pubic  incision, 
freshening  the  edge  of  the  fistula,  and  suture  of  the  base  of  the 
bladder  as  after  the  removal  of  a  tumor,  care  being  taken  to 
avoid  constriction  of  the  ureters.  The  ingenuity  of  the  surgeon 
will  be  taxed  to  the  utmost  in  these  cases  in  order  that  a  suffi- 
cient amount  of  tissue  may  be  secured  for  denudation  and  repair, 


172  DISEASES   AND   INJURIES   OF   THE  VAGINA 

and  it  may  be  necessary  to  utilize  the  anterior  wall  of  the  supra- 
vaginal portion  of  the  cervix  for  this  purpose. 

The  preparatory  and  after-treatment  are  the  same  as  for 
smaller  fistulae,  even  more  attention  being  given  to  securing 
healthy  bladder  and  vaginal  walls  previous  to  operation,  and  to 
preventing  distension  of  the  bladder  afterward. 

Operation  for  Recto-vaginal  Fistulae. — Owing  to  the  laxness 
of  the  tissue  in  the  recto-vaginal  septum  above  the  perineum, 
these  fistulae  are  more  readily  closed  than  those  just  discussed. 
The  smaller  ones  are  handled  precisely  like  small  vesico-vaginal 
fistulae,  viz.,  by  denudation  and  approximation  of  a  broad  area 
on  the  vaginal  side  of  the  orifice. 

Larger  openings  should  have  the  rectal  and  vaginal  walls 
sutured  separately.  This  may  be  done  by  splitting  the  edge 
of  the  fistula,  or  if  the  opening  is  not  too  high  in  the  vagina,  by 
separation  of  the  rectum  and  vagina  as  in  the  flap-splitting 
operation  for  perineal  laceration,  and  suture  of  the  opening  in 
the  rectal  wall  through  the  space  thus  gained.  Denudation 
and  suture  of  the  margins  of  the  opening  in  the  vaginal  wall  is 
then  made  from  the  vaginal  surface. 

A  characteristic  small  fistula  sometimes  persists  after  the 
repair  of  complete  perineal  laceration.  These  fistulae  usually 
open  into  the  rectum  just  above  the  internal  anal  sphincter,  and 
their  vaginal  orifice  may  be  at  any  point  above  the  anterior 
edge  of  the  perineum.  They  sometimes  heal  under  the  use 
of  the  actual  cautery  but  frequently  demand  a  less  extensive 
repetition  of  the  original  operation  with  complete  excision  of 
the  fistulous  tract. 

The  sphincter  ani  should  be  paralyzed  by  thorough  dilatation 
before  the  operation  proper  is  begun  in  order  that  gas  and  liquid 
feces  may  escape  through  the  anus  instead  of  bringing  pressure 
to  bear  upon  the  suture  line,  and  the  care  of  the  bowels  should 
be  the  same  as  after  the  repair  of  complete  laceration  of  the 
perineum. 

In  some  recto-vaginal  fistulae  the  simplest  method  of  procedure 


REFERENCES  I 73 

is  to  incise  the  entire  recto-vaginal  septum  from  the  fistulous 
tract  to  and  through  the  perineal  body  and  sphincter  ani,  thus 
making  a  complete  laceration  of  the  perineum.  The  edges  of 
the  fistula  are  then  freshened,  preferably  by  spHtting  the  vaginal 
from  the  rectal  wall,  and  the  sutures  are  applied  as  in  the  opera- 
tion for  complete  perineal  laceration. 
Atresia  of  the  Vagina. — See  Chap.  XV. 

• 

REFERENCES 

MEISTER. — Vaginitis.     Am.  J,  ObsL,  1910,  Ixi,  540. 

KIESSELBACH. — Ueber  Papillome  der  Vagina.     Monats.  /.  Geh.  b°  Gyn.,  191 2, 

xxxvi,  404. 
PILSBY. — Ueber  Colpitis  seniles.     Med.  Klin.,  1906,  ii,  1087. 
"WOLFF. — The  Treatment  of  Gonorrheal  Vaginitis  in  Children  with  Autogenous 

Vaccines.     Chicago  Med.  Rec,  1913,  xxxv,  462. 
CURTIS. — On  the  Pathology  and  Treatment  of  Chronic  Leucorrhea;  A  Study 

of  the  Causes  of  Purulent  Vaginal  Discharge  and  the  Results  of  Various 

Kinds  of  Treatment.     Surg.,  Gyn.  &°  Obst.,  1914,  xix,  25. 
ABRAHAM,  O. — Neure  Versuche  ueber  die  Hefebehandlung  des  Weiblichen 

Fluors.     Monats.  f.  Geh.  undGyn.,  1910,  xxxi,  89. 
OPPENHEIM,  H.— Zur  Puderhandlung  des  Weiblichen  Fluors.     Berlin  Klin. 

Woch.,  19 14,  li,  604. 
PUPPEL. — Trochenbehandlung  des  Fluors  albus.     Fortsch.  d.  Med.,  1913,  xxxi, 

714;  Internal.  Abst.  Surg.,  Feb.,  1914,  164. 
GOODMAN. — Diphtheritic  Vaginitis.     Am.  J.  Obst.,  1914,  Ixix,  272. 
McFARLAND,  J. — Sarcoma  of  the  Vagina.     Am.  J.  Med.  Sci.,  191 1,  cxli,  570. 
KUSTER. — Beitrag  zur  Kenntnis  der  sogenannten  Scheidencysten.     Zeitsch. 

/.  Geb.  und  Gyn.,  1913,  Ixxiv,  611. 
MURRAY. — Vaginal  Cysts  and  Their  Histology.     Am.  J.  Obst.,  1910,  Ixi,  925. 
PETTMANN. — Zur   Technik    der   Radikaloperation    des   primaren    Scheiden- 

krebses.     Monats.  f.  Geb.  undGyn.,  1911,  xxxiii,  56. 
HOEHNE,  O. — Ueber  das  Primare  Adenokarzinom  der  Vagina.    Zeitsch.  f. 

Geb.  und  Gyn.,  19 10,  Ixvii,  50. 
BLAND. — Sarcoma  of  the  Vagina.    /.  A.  M.  A.,  1912,  lix,  509. 
HART. — Adenoma  Vaginae  Diffusum,  with  a  Critical  Discussion  of  Present 

Views  of  Vaginal  and  Hymeneal  Development.     Edin,  M.  /.,  1911,  vi,  577. 
LOHNBERG. — Ein  Fall  von  Primarem  Scheidenkarzinom  und  Leukoplakie. 

Zeitsch.  f.  Geb.  und  Gyn.,  1913,  Ixxiii,  755. 
KELLY. — The  History  of  the  Vesico-vaginal  Fistula.     Tr.  Am.  Gyn.  Assn., 

1912,  xxxvii,  3, 
MARCY, — Vesico-vaginal   Fistula   and   Recto- vaginal  Fistula.     /.  A.  M.  A., 

1914,  Ixiii,  238. 


174  DISEASES   AND   INJURIES   OF   THE  VAGINA 

BECKMAN. — Zur  Technik  der  Blasencheidenfisteloperationen.     Zeitsch.  f.  Geb. 

utui  Gyn.,  1912,  Ixx,  120. 
VON  OTT. — Eine  neue  Modifikation  in  der  operativen  Behandlung  einiger  Mast- 

darmscheidenfisteln.     Zentralb.  f.  Gyn.,  1908,  xxxii,  577, 
BA£R. — Vesiko vaginal fistel.    auf   intravesikalem  Wege   Geschlossen.     Munch. 

tned.  Wchn.,  1913,  Ix,  2053. 
THOMSON. — Operation  grosser  Rectovaginalfisteln.     Centralb.  f.  Gyn.,  1910, 

xxxiv,  801. 


CHAPTER  VII 
DISEASES  AND  INJURIES  OF  THE  CERVIX 

Erosion. — The  normal  covering  of  that  portion  of  the  cervix 
which  projects  into  the  vagina,  the  "portio- vaginalis,"  is 
stratified  squamous  epithelium  and  its  color  varies  from  the  gray 


Fig.  78.' — Normal  cervicarepitlielmm.  Because  the  material  is  cut  to  a  very- 
slight  extent  at  an  oblique  angle  the  number  of  layers  of  cells  appears  to  be  some- 
what increased,  but  not  to  a  marked  degree. 

pink  of  the  vaginal  mucosa  to  a  grayish  purple.     The  color  of 
the  mucosa  within  the  cervical  canal  is  a  deep  red. 

Under  the  influence  of  infection  of  the  mucosa  of  the  cervical 

175 


176 


DISEASES   AND   INJURIES   OF   THE   CERVIX 


canal,  or  the  constant  irritation  associated  with  everted  cervical 
lips  following  cervical  laceration  and  low-grade  infection,  the 
squamous  epithelium  about  the  vaginal  portion  of  the  cervix  is 
replaced  by  columnar  epithelium,  and  the  color  of  the  involved 
part  of  the  portio-vaginaHs  becomes  the  same  as  that  of  the 
cervical  canal.     This  condition  is  known  as  erosion  and  is  popu- 


FiG.  79. — This  section  shows  a  typical  area  of  glandular  erosion  with  beginning 
healing.  There  are  three  areas  shown  in  which  the  surface  is  covered  with  a 
simple  columnar  epithelium  instead  of  a  stratified  squamous.  Between  these 
are  islands  of  fairly  normal  epithelium.  These  are  growing  over  and  under  the 
glandular  elements  in  an  attempt  to  produce  healing.  At  the  extreme  left  the 
squamous  epithelium  is  undermining  the  gland  and  apparently  trying  to  enu- 
cleate it.     This  is  another  method  of  healing. 

larly  but  incorrectly  termed  ulceration.  The  only  symptom 
produced  is  a  muco-purulcnt  leucorrheal  discharge  which  may 
be  blood  streaked  after  coitus.  Upon  digital  examination  the 
surface  about  the  external  os  has  a  soft,  slippery,  velvety  feel 
and  frequently  it  bleeds  as  a  result  of  examination.  In  conse- 
quence of  agglutination  of  the  mouths  of  the  glands  which  open 


EROSION   OF   THE   CERVIX  1 77 

upon  the  surface  of  the  cervix,  retention  of  secretion  occurs  pro- 
ducing Nabothian  foUicles  which  feel  Hke  hard,  round  elevations. 
They  are  rare  in  nulliparous  cervices,  but  quite  common  in 
women  who  have  borne  children.  Erosion  is  recognized  and  its 
extent  appreciated  upon  inspection.  It  should  not  be  mistaken 
for  eversion  of  the  cervical  mucosa,  for  true  ulceration,  or,  most 
important  of  all,  for  cancer. 

Apparent  erosion,  due  to  hyperplasia  and  rolling  out  of  the 
mucosa  within  the  cervical  canal,  is  distinguished  by  its  appear- 
ance. True  ulceration  always  exhibits  loss  of  substance,  while 
erosion  does  not.  Moderately  advanced  carcinoma  breaks 
down  readily  under  the  finger  and  there  is  actual  new  growth. 
Advanced  cancer  presents  both  new  growth  and  excavation. 
Early  cancer  gives  no  pathognomonic  evidence  of  its  presence 
without  microscopic  examination,  wherefore,  during  the  cancer 
age  an  erosion  which  Jails  to  heal  under  a  few  local  applications 
is  an  indication  for  the  removal  for  microscopic  examination  of 
a  small  section  of  that  portion  of  the  cervix  which  underlies  the 
erosion. 

Nabothian  follicles  are  diagnosed  by  puncture  and  evacuation 
of  the  retained  secretion  which  consists  of  a  whitish  viscid 
mucus. 

Treatment. — Eroded,  lacerated  cervices  in  women  beyond  the 
child-bearing  age  should  be  amputated.  Erosion  of  the  unin- 
jured cervix  should  be  treated  by  attention  to  the  infected 
mucosa  of  the  cervical  canal  as  well  as  the  erosion  itself. 

Non-malignant  erosion  will  heal,  temporarily  at  least,  after  a 
few  applications  of  strong  nitrate  of  silver  solution  (10-20  per 
cent.)  or  very  light  application  of  the  solid  stick  together  with 
the  daily  use  of  astringent  douches,  of  which  tannic  acid  in  3^^  to 
I  per  cent,  solution  is  the  best. 

Unless  the  original  exciting  cause  is  done  away  with,  whether 
it  be  laceration  or  cervical  infection,  the  erosion  is  certain  to 
recur. 

12 


178 


DISEASES    AND   INJURIES    OF   THE   CERVIX 


Endocervicitis  and  Cervical  Polypi. — The  normal  cervical 
discharge  is  a  thick,  glairy,  slightly  opaque  mucus  which  is 
secreted  in  small  amounts.  Hypersecretion  of  a  similar  mucus 
may  be  brought  about  by  congestion  and  in  some  instances  by 
unknown  causes. 

Inflammation,  however,  is  due  to  infection  which  not  only 
causes  an  increase  in  the  quantity  of  normal  mucus,  but  an  ad- 
mixture of  pus  as  well. 


Fig.  8o. — Cervical  polyp. 


An  obstructed  oedematous  gland  projects  from  the 
cervix  as  a  polypus. 


In  chronic  endocervicitis  the  cervical  mucosa  undergoes 
hyperplasia  and  may  roll  out  of  the  external  uterine  orifice,  or 
if  a  gland  becomes  obstructed  and  the  retained  secretion  renders 
it  oedematous,  it  projects  from  the  external  cervical  orifice  as 
a  distinct  polypus. 

The  chief  sources  of  infection  are  gonorrhea,  infection  during 


ENDOCERVICITIS  1 79 

labor,  and  infection  during  the  puerperium  of  unhealed  injuries 
occurring  at  the  time  of  labor. 

Acute  infection  of  the  cervix  is  prone  to  extend  to  the  endome- 
trium of  the  uterine  body  by  continuity  of  tissue,  or  to  the  ovaries 
through  the  lymphatics  at  the  base  of  the  broad  ligament. 

Chronic  infection  seldom  extends  to  the  body  of  the  uterus  and 
infections  which  primarily  were  acute,  but  have  subsided,  are 
almost  always  confined  to  the  cervix.  ^^  Chronic  purulent  endo- 
metritis^^ really  is  chronic  endo cervicitis,  the  body  of  the  uterus 
readily  ridding  itself  of  Hngering  infection,  possibly  through 
the  exfoHation  of  epithelium  which  occurs  at  each  menstrual 
period. 

The  symptoms  of  acute  endocervicitis  are  limited  to  a  feeling 
of  weight  and  bearing  down  in  the  pelvis,  sacral  backache,  and 
muco-purulent  leucorrhea.  By  digital  examination  no  change 
can  be  detected  unless  erosion  is  also  present,  but  on  inspection  a 
ropy  purulent  discharge  is  seen  escaping  from  the  cervix,  the 
mucosa  of  which  may  or  may  not  be  everted. 

In  chronic  endocervicitis  the  same  symptoms  are  present,  and 
in  long-standing  cases  there  may  be  considerable  pain  in  the 
hypogastric  regions.  On  vaginal  palpation  it  is  often  possible 
to  detect  an  indistinct  resistance  in  the  bases  of  the  broad  Kga- 
ments,  and  pressure  through  the  lateral  vaginal  fornices  repro- 
duces the  pain  of  which  the  patient  complains. 

True  cervical  polypi  whose  origin  is  described  above  usually 
give  rise  to  no  symptoms  other  than  irregular  bleeding.  Ordi- 
narily this  is  not  profuse  and  consists  of  "spotting"  upon  exer- 
tion, after  taking  a  douche,  or  following  coitus.  Occasionally, 
however,  polypi  bleed  freely  enough  to  give  rise  to  a  consider- 
able degree  of  anaemia.  These  polypi  project  from  the  cervix 
as  small,  pedunculated,  bright  red  growths  which  bleed  readily 
to  the  touch  and,  although  quite  soft,  the  larger  ones  are  per- 
ceptible to  the  finger  upon  digital  examination. 

Treatment, — Trifling  hypersecretion  without  infection  can  be 
cured  by  measures  designed  to  reHeve  congestion,  but  appKca- 


l8o  DISEASES   AND   INJURIES    OF   THE   CERVIX 

tions  to  the  interior  of  the  cervical  canal  are  entirely  ineffectual 
for  this  purpose.  Saline  cathartics,  prolonged  hot  douches,  local 
blood  letting  once  or  twice  a  week  accomplished  by  stabbing  the 
portio-vaginalis  in  half  a  dozen  places  with  a  fine  bistoury,  and 
the  application  of  a  glycerine  tampon  are  usually  sufficient. 
Severe  cases  of  hypersecretion  can  be  cured  only  by  destruction 
of  the  cervical  glands  or  by  amputation  of  the  cervix  according  to 
Schroeder's  method. 

In  acute  endocervicitis  it  is  possible  to  mitigate  and  even  cure 
an  occasional  case  by  direct  applications  to  the  cervical  canal, 
but  the  greatest  care  must  be  taken  not  to  introduce  instru- 
ments above  the  internal  uterine  orifice  whose  constriction  offers 
a  natural  barrier  to  the  ascent  of  infection.  Powerful  anti- 
septics do  no  harm  in  the  cervical  canal  providing  they  are  not 
escharotic,  but  none  of  them  penetrate  the  glands  which  harbor 
micro-organisms.  Local  applications  must  for  this  reason  be 
used  very  early  and  while  the  infection  is  still  superficial  in 
order  to  be  of  any  service.  The  tenacious  muco-pus  which  plugs 
the  cervix  must  first  be  removed  with  a  cotton-wrapped  appli- 
cator, and  following  this  the  cervical  canal  is  thoroughly  mopped 
with  tincture  of  iodine,  pure  cairboHc  acid,  or  strong  nitrate  of 
silver  solution,  being  careful  when  carbolic  acid  is  used  not  to 
allow  it  to  drop  on  the  vagina  or  vulva.  Douches  have  no 
particular  effect  upon  the  cervical  canal,  but  they  reheve  local 
congestion  and  maintain  cleanhness  of  the  vagina.  Should  the 
discharge  persist  more  than  a  few  weeks  it  is  impossible  to 
effect  a  cure  by  local  applications  alone,  and  they  should  Hke- 
wise  be  abandoned  if  the  infection  spreads  to  the  corporeal  endo- 
metrium and  the  tubes. 

In  the  instances  of  long-continued  purulent  cervical  leucorrhea 
just  mentioned,  as  well  as  those  which  are  chronic  when  first 
seen,  it  is  possible  to  effect  a  cure  by  dilating  the  cervix  with 
Sims's  dilators  and  making  applications  to  it  in  a  manner  similar 
to  that  employed  in  sounding  and  treating  a  persistent  inflam- 
matory patch  in  the  male  urethra,  but  the  risk  of  carrving  infec- 


LACERATION   OF   THE   CERVIX  l8l 

tion  into  the  cavity  of  the  body  of  the  uterus  is  too  great  to 
justify  the  adoption  of  this  method. 

The  best  non-operative  treatment  is  that  devised  at  the  Johns 
Hopkins  Hospital  of  Hght  cauterization  with  the  fine  point  of 
the  thermo-cautery,  making  several  linear  strips  throughout 
the  length  of  the  cervical  canal  and  repeating  the  procedure  at 
intervals  of  from  ten  days  to  two  weeks.  Deep  cauterization  is 
unnecessary  and  may  lead  to  stenosis.  In  very  obstinate  cases, 
Schroeder's  amputation  should  be  performed  as  advised  for 
hypersecretion. 

Polypi  should  be  twisted  off  or  scraped  away  with  the  sharp 
curette  and  have  their  bases  cauterized. 

Laceration  of  the  Cervix. — Some  laceration  of  the  cervix 
occurs  at  every  labor  but  unless  the  injury  is  quite  deep  or  in- 
fection takes  place  it  is  likely  to  heal  without  difficulty,  although 
the  lips  sometimes  fail  to  unite  even  under  the  most  favorable 
circumstances  and  thus  leave  two  adjacent  surfaces  which, 
while  ununited,  are  completely  covered  by  squamous  epithe- 
lium. These  injuries  are  of  no  importance.  Deep  lacerations 
and  those  which  become  infected  fail  either  to  unite  or  to  become 
covered  with  squamous  epithelium,  and  a  chronic  cervicitis  and 
endocervicitis  takes  place  which  results  in  erosion,  eversion  of 
the  lips,  connective- tissue  formation,  and  hypertrophy  of  the 
entire  infra-vaginal  cervix  with  obstruction  of  the  cervical 
glands.  Such  cervices  subsequently  may  become  malignant; 
in  fact  carcinoma  of  this  portion  of  the  cervix  is  rare  unless  it 
has  been  preceded  by  the  chronic  irritation  of  an  unhealed 
eroded  laceration. 

Symptoms. — ^Lacerations  which  unite  or  become  covered  with 
squamous  epithelium  give  rise  to  no  symptoms. 

Those  lacerations  which  fail  to  heal  in  one  or  the  other  of 
the  above-mentioned  ways  give  rise  to  leucorrhea,  and  quite 
often  to  considerable  discomfort  which  is  referred  to  the  hypo- 
gastric regions.  There  is  also  backache  of  the  familiar  sacral 
variety.     The  older  gynaecologists  laid  great  stress  upon  a  long 


1 82  DISEASES   AND   INJURIES   OF   THE   CERVIX 

chain  of  remote  reflex  symptoms  which  were  said  to  follow  this 
injury  and  to  be  due  to  compression  of  nerves  in  the  scar.  It 
is  likely  that  these  so-called  reflex  symptoms  are  concomitants 
only,  and  that  the  only  systemic  results  of  cervical  laceration 
are  such  as  are  produced  by  the  pelvic  discomfort  and  discharge. 
By  themselves  these  are  not  suJBEicient  to  cause  any  serious 
general  symptoms,  and  the  latter  are  chiefly  due  to  the  worry 
and  anxiety  which  many  women  suffer  when  unduly  influenced 
by  the  idea  that  they  have  something  wrong  with  the  womb. 
An  immediate  diagnosis  can  be  made  by  digital  examination, 
although  inspection  through  the  speculum  should  not  be  neg- 
lected. The  cervix  is  harder  than  normal,  the  everted  lips  can 
be  recognized  and  there  is  often  a  palpable  tender  band  ex- 
tending from  the  apex  of  the  tear  into  the  vaginal  vault  or 
even  into  the  base  of  the  broad  ligament.  That  the  ovaries 
are  sometimes  tender  is  not  surprising  when  their  lymphatic 
supply  is  considered. 

On  examination  with  the  speculum  the  condition  is  better 
appreciated,  and  erosion,  Nabothian  follicles,  etc.,  can  be  seen. 

Beginning  malignant  degeneration  is  not  easily  diagnosed  in 
the  hypertrophied  eroded  lips  of  a  cervix  which  has  been  the 
seat  of  a  long-standing  laceration,  and  the  tissues  from  such 
cervices  should  be  submitted  to  microscopic  examination,  before 
operation  if  intermittent  bleeding  has  been  present,  and  after 
operation  in  any  event. 

Treatment. — Much  discussion  has  been  provoked  by  the 
proposal  to  repair  all  cervical  injuries  immediately  at  the  com- 
pletion of  labor.  Owing  to  the  risk  of  infection,  the  impossi- 
bility of  coapting  the  wound  edges  so  that  they  do  not  separate 
during  involution,  and  the  large  number  of  tears  which  unite 
spontaneously,  the  greater  number  of  obstetricians  and  gynae- 
cologists advise  against  routine  interference  at  this  time.  In  the 
event  that  deep  laceration  is  productive  of  severe  hemorrhage 
a  suture  about  the  apex  of  the  tear  is  necessary,  and  under  such 
circumstances   complete   repair   may   be   attempted.     Hirst's 


HYPERTROPHY   OF   THE    CERVIX  1 83 

proposal  to  repair  such  injuries  during  the  puerperium  is  not 
practicable  outside  of  well-regulated  hospitals,  and  the  question 
of  its  advisability  is  still  sub-judice. 

As  stated  above,  healed  lacerations  with  thin  cervical  lips, 
whether  the  edges  are  united  or  merely  covered  by  squamous 
epitheHum,  need  absolutely  no  attention. 

Conversely,  all  eroded  or  thickened  cervices  in  women  near 
the  menopause  should  be  repaired  or  amputated,  preferably  the 
latter. 

During  the  active  child-bearing  period  the  proper  course  to 
pursue  is  a  matter  of  judgment.  If  the  symptoms  are  very 
annoying,  a  repair  should  be  made  regardless  of  the  fact  that 
another  labor  might  reproduce  the  injury.  If  the  symptoms 
are  trivial  no  operation  should  be  performed.  It  is  possible 
in  these  latter  cases  to  overcome  the  erosion  temporarily  and 
check  the  discharge  by  the  daily  use  of  prolonged  hot  douches, 
the  local  application  of  tincture  of  iodine,  occasional  scarifica- 
tion if  the  congestion  is  intense,  and  the  use  of  the  boro-glyceride 
tampon.  Permanent  cure  is  hardly  to  be  expected,  but  sufficient 
relief  may  be  obtained  so  that  operation  is  not  called  for  until 
a  later  period  of  the  patient's  life  when  subsequent  labor  is  not 
likely  to  undo  the  operative  results. 

Hypertrophy  of  the  Cervix. — Hypertrophy  from  cervicitis  is 
one  of  the  results  of  the  irritation  of  an  old  laceration,  but 
aside  from  this  there  are  instances  of  so-called  supra-vaginal 
elongation  of  the  cervix.  Some  of  these  are  congenital  and  are 
found  in  virgins.  Others  are  found  where  there  is  great  relaxa- 
tion of  the  vaginal  walls  and  outlet,  when  they  simulate  prolapse 
of  the  uterus,  but  the  fundus  is  in  its  normal  location  and  posi- 
tion. It  is  likely  that  the  tugging  of  the  attached  bladder  and 
vaginal  walls  is  responsible  for  the  condition,  the  body  of  the 
uterus  being  supported  sufficiently  well  to  obviate  dislocation  of 
the  uterus  as  a  whole. 

The  treatment  of  hypertrophy  due  to  laceration  is  that  of 
laceration  itself.     In  congenital  hypertrophy,  circular  amputa- 


184  DISEASES   AND   INJURIES    OF   THE   CERVIX 

tion  may  be  performed  if  the  protruding  cervix  is  a  serious 
annoyance.  If  hypertrophy  is  associated  with  cystocele  and 
relaxed  vaginal  outlet,  the  appropriate  operations  for  these 
conditions  should  be  performed,  together  with  high  amputation 
of  the  cervix. 

Stenosis  of  the  Cervix. — Atresia  or  complete  occlusion  of  the 
cervix  is  a  congenital  anomaly  and  is  treated  under  that  heading. 
Stenosis  or  narrowing  of  the  cervix  to  a  pathological  degree  may 
also  exist  from  birth,  or  it  may  be  the  result  of  an  imperfect 
operation  for  cervical  repair.  Congenital  stenosis  either  of  the 
internal  or  external  uterine  orifice  has  long  been  considered  one 
of  the  classical  causes  of  dysmenorrhea,  but  in  the  absence  of 
such  menstrual  anomalies  as  membranous  endometritis,  or 
menorrhagia  with  the  formation  of  clots  in  the  uterus,  actual 
symptoms  arising  from  congenital  cervical  stenosis  are  very  rare. 

Cicatricial  contraction  of  a  badly  repaired  cervix  may  on 
the  contrary  result  in  a  high-grade  obstruction,  and  be  produc- 
tive of  pain  from  actual  interference  with  the  outflow  of  men- 
strual blood.  Such  pain  is  distinctly  rhythmic  and  cramp-like 
in  character. 

Stenosis  which  is  not  cicatricial  in  origin  is  overcome  readily 
by  forcible  dilatation  under  anaesthesia.  Cicatricial  stenosis  of 
moderate  degree  may  be  cured  by  gradual  dilatation,  but  if  the 
scar  tissue  is  very  extensive  and  the  degree  of  narrowing  marked, 
re-operation  by  amputation  is  to  be  preferred. 

TUMORS   OF   THE   CERVIX 

True  fibromata  and  myomata  originating  in  the  infra-vaginal 
portion  of  the  cervix  are  rare.  When  present,  they  form  rounded 
encapsulated  tumors  which  do  not  tend  to  be  extruded  through 
the  cervical  canal.  Most  so-called  cervical  fibroids  are  tumors 
of  the  supra-vaginal  cervix  or  body  of  the  uterus  which  have 
been  partially  expelled.  The  true  cervical  fibroid  must"  be 
distinguished  from  adeno-carcinoma,  and  like  any  new  growth 


CARCINOMA   OF   THE   CERVIX  1 85 

springing  from  the  cervix  it  is  under  suspicion  until  proven  not 
malignant  by  microscopic  examination. 

These  tumors  rarely  attain  great  size  and  may  usually  be  enu- 
cleated in  the  same  manner  as  are  small  sessile  tumors  in  the  wall 
of  the  body  and  fundus  of  the  uterus. 

Carcinoma  of  the  Cervix. — It  is  estimated  that  carcinoma  of 
the  cervix  comprises  one-third  of  all  carcinomata  occurring  in 
women,  and  the  cervix  is  the  place  of  origin  of  the  vast  majority, 
possibly  90  per  cent.,  of  all  uterine  carcinomata.  While  cancer  of 
the  breast  is  also  common,  following  cancer  of  the  uterus  and 
stomach  in  the  order  of  frequency,  its  first  symptom  is  the 
appearance  of  a  tumor  of  which  the  patient  is  aware;  while  the 
first  symptom  of  cancer  of  the  cervix  is  bleeding  to  which  the 
patient  is  accustomed,  and  to  which  she  therefore  attaches  but 
little  importance. 

Etiology. — While  the  cause  of  cancer  in  general  is  unknown, 
it  is  certain  that  it  has  a  marked  predilection  for  areas  which 
have  undergone  chronic  irritation.  Cancer  rarely  attacks  a 
cervix  which  has  not  been  injured. 

Pathology. — Following  the  rule  that  the  type  of  cancer  is 
dependent  upon  the  variety  of  epithelium  covering  the  surface 
in  which  it  originates,  two  distinct  types  of  carcinoma  are  found 
in  the  cervix.  These  types  are  the  squamous-celled  carcinoma 
or  epithelioma,  and  the  glandular  or  adeno-carcinoma.  Either 
of  these  types  further  may  show  its  most  marked  growth  outward 
from  the  surface  of  the  cervix,  forming  a  medullary  or  cauli- 
flower carcinoma,  or  downward  into  the  cervical  tissue,  forming 
an  infiltrating  carcinoma.  It  is  said  that  the  degree  of  vascu- 
larity determines  the  direction  of  the  growth,  the  more  vas- 
cular growing  outward,  the  less  vascular  infiltrating.  Both 
forms  tend  eventually  to  break  down  in  the  center  and  infiltrate 
at  their  bases.  Histologically  the  squamous-celled  cancer 
differs  from  normal  cervical  tissue  in  that  the  epithelial  cells 
not  only  cover  the  surface  but  penetrate  into  the  cervical  tissue, 
the  latter  forming  the  stroma  of  the  new  growth.     The  cells  are 


i86 


DISEASES   AND    INJURIES    OF   THE   CERVIX 


closely  packed  together  and  give  evidence  of  recent,  rapid,  irreg- 
ular growth  by  the  presence  of  mitotic  figures,  and  epitheHal 
pearls  are  sometimes  seen. 

Histologically  the  adeno-carcinoma  shows  the  development 
of  a  new  gland  formation  which  differs  from  the  normal  glandu- 
lar structure  of  the  parts  in  that  the  glands  are  irregular  in 


;V';^.-^  v\ 


Fig.  8i. — Early  squamous  celled  carcinoma  of  the  cervix.  While  one  can 
never  be  certain  that  such  atypical  ingrowths  as  these  would  have  become  deeply 
infiltrating  if  allowed  to  remain,  still  we  find  all  gradations  and  such  a  section  as 
this  must  be  diagnosed  as  early  carcinoma. 


shape  and  size,  that  they  anastomose  with  each  other,  and  that 
the  gland  lumen  is  lined  in  places  by  many  layers  of  cylindrical 
epithelium  instead  of  one.  The  larger  works  on  pathology 
should  be  consulted  with  reference  to  the  details  of  the  various 
histological  pictures  which  may  be  found. 

The  squamous-celled  cancer  affects  principally  the  vaginal 


CARCINOMA   OF   THE   CERVIX 


187 


portion  of  the  cervix,  while  the  cyHndrical-celled  affects  prim- 
arily the  tissues  surrounding  the  cervical  canal.  Either  form 
may  by  its  growth  invade  the  territory  which  the  other  by 
preference  involves,  and  both  ahke  sooner  or  later  infiltrate  the 
neighboring  structures  and  spread  into  the  connective  tissue 


Fig.  82. — Far  advanced  squamous  celled  carcinoma  of  the  cervix.  Originat- 
ing in  the  mucosa  of  the  cervix  but  here  infiltrating  the  musculature  of  the  lower 
portion  of  the  uterus.     The  infiltration  in  this  case  extended  nearly  to  the  serosa. 

which  surrounds  the  supra-vaginal  cervix,  technically  known  as 
the  parametrium.  Eventually  the  vaginal  wall,  the  vesico- 
vaginal septum,  and  the  recto-vaginal  septum  may  be  destroyed 
by  the  growth.  Involvement  of  the  parametrium  usually  im- 
plicates the  ureters,  narrowing  their  caliber  and  leading  to 
hydronephrosis. 


1 88  DISEASES   AND   INJURIES    OF   THE   CERVIX 

The  neighboring  lymph  glands  are  frequently  but  not  so 
regularly  involved  as  is  the  case  in  some  other  portions  of  the 
body  like  the  tongue  and  female  breast,  but  the  extension  of 
the  growth  beyond  its  palpable  limits  is  always  surprising. 

Symptoms. — Pain,  foul  discharge,  and  cachexia  are  the  popu- 
larly accepted  symptoms  of  cancer  of  the  cervix,  and  they  are, 
when  it  has  reached  a  hopeless  stage.  Irregular  slight  hemor- 
rhage after  exertion,  a  douche,  coitus,  or  even  spontaneously, 
is  usually  the  earliest  symptom  of  cancer  of  the  cervix,  and 
supposed  recurrence  of  menstruation  after  the  menopause  is 
past  is  always  to  be  viewed  with  suspicion.  Sometimes,  but 
not  often,  a  watery  leucorrheal  discharge  precedes  the  appear- 
ance of  hemorrhage.  These  earliest  symptoms  are  followed  by 
the  triad  first  mentioned,  with  increase  of  the  hemorrhage  and 
marked  foulness  of  the  discharge. 

Pain  is  an  extremely  uncertain  and  variable  symptom  and  is 
dependent  upon  the  structures  attacked,  but  it  is  rarely  absent 
in  the  later  stages. 

Hemorrhage  usually  becomes  more  marked  as  the  case 
proceeds  and  may  itself  cause  death,  but  an  occasional  case 
runs  its  course  with  comparatively  little  bleeding.  Cachexia, 
probably  due  to  absorption  from  the  broken  down  surfaces,  is 
progressive  after  it  once  begins  and  the  fetor  of  late  cancer  is 
overwhelming.  The  temperature  is  irregularly  elevated  and 
the  pulse  is  proportionate  both  in  rate  and  quality  to  the  degree 
of  ana^'mia  and  exhaustion,  and  an  irregular  leucocytosis  is 
usually  present.  While  death  may  come  from  uraemia  due  to 
obstruction  of  the  ureters,  it  is  usually  due  to  exhaustion  from 
hemorrhage,  toxaemia,  and  pain. 

Physical  Signs  and  Diagnosis. — Early  in  the  disease  digital 
examination  reveals  an  area  of  induration  in  one  or  the  other 
of  the  cervical  lips,  providing  the  growth  is  situated  in  theportio- 
vaginalis  and  not  high  up  within  the  cervical  canal.  In  the 
latter  event  nothing  abnormal  may  be  perceptible  to  the  touch. 
One  sign  of  pathognomonic  importance  is  the  sensation  conveyed 


DIAGNOSIS  OF  CARCINOMA  OF  THE  CERVIX  1 89 

to  the  examining  finger  of  stony  hardness  or  great  density  of 
the  involved  tissue,  this  dense  portion  not  being  perfectly  regu- 
lar in  outline  as  is  a  Nabothian  follicle.  Scar  tissue  in  the  cervix 
is  hard,  but  if  one  can  so  express  it,  the  quality  is  different. 
The  second  pathognomonic  feature'  of  cancerous  tissue,  fria- 
bility, cannot  be  made  out  in  the  infiltrating  type  until  the  dis- 
ease has  broken  through  the  mucosa.  On  inspection  of  an 
early  cancer  through  the  speculum  only  the  enlarged  thickened 
lip  may  be  apparent.  Occasionally,  minute  yellow  dots  may 
be  seen  projecting  outward  into  the  mucosa  before  actual 
breaking  down  has  occurred.  The  only  enlargement  of  the 
cervix  likely  to  confuse  one  in  the  early  stage  is  fibroma,  and 
while  fibroma  is  hard  it  does  not  feel  so  dense  and  the  outlines 
of  the  tumor  are  more  likely  to  be  regular.  If  nothing  abnormal 
is  apparent  to  the  touch  and  sight,  but  suspicious  subjective 
symptoms  are  present,  the  condition  of  the  upper  portion  of  the 
cervical  canal  should  be  investigated,  and  this  being  healthy 
the  uterine  body  itself  must  be  considered  as  diseased  until  the 
contrary  can  be  proven. 

Nothing  should  be  taken  for  granted.  If  there  is  the  shghtest 
doubt  as  to  the  character  of  any  thickened  tissue,  nodule, 
erosion,  or  ulcerated  area,  a  portion  should  be  removed  for 
microscopic  examination  by  a  competent  pathologist. 

Late  in  the  course  of  the  disease  the  physical  evidences  are 
unmistakable.  Either  the  cauliflower  excrescence  of  the  papil- 
lary form  or  the  deep  ulceration  of  the  infiltrating  type  are 
perceptible  to  the  touch,  and  both  present  the  characteristic 
features  of  cancerous  tissue,  viz.,  stony  hardness  combined 
with  great  friabihty.  Hemorrhage  upon  digital  examination  is 
also  an  invariable  accompaniment  of  late  cervical  carcinoma. 
Inspection  reveals  the  same  condition  as  palpation,  either 
cauliflower  growth  or  deep  excavation.  Only  two  benign  con- 
ditions are  at  all  likely  to  lead  to  error,  cervical  gumma  and 
sloughing  sub-mucous  fibroma.  Cervical  gumma  is  so  rare  as  to 
be  negligible.     Sloughing  sub-mucous  tumors,  which  have  been 


1 90  DISEASES   AND  INJURIES   OF  THE   CERVIX 

extruded  into  the  cervix,  may  give  rise  to  foul  discharge,  bleed- 
ing, and  pain,  and  on  examination  a  broken  down  mass  may  be 
found  in  the  vaginal  vault,  but  these  necrotic  tumors  are  at- 
tached by  a  pedicle  which  extends  into  the  uterine  cavity,  they 
are  not  dense,  and  unless  the  process  is  far  advanced  the  mucosa 
covering  them  is  plainly  visible. 

Treatment. — The  treatment  of  carcinoma  of  the  cervix  is  the 
same  as  the  treatment  of  carcinoma  in  any  other  accessible  loca- 
tion, radical  extirpation  so  long  as  the  disease  is  so  localized 
that  extirpation  offers  any  hope  of  success,  and  palliative  treat- 
ment when  radical  operation  is  not  feasible.  The  diagnosis  of 
operability  is  thus  second  in  importance  only  to  the  diagnosis  of 
the  disease  itself.  Clinically,  extension  of  cancerous  infiltration 
into  the  parametrium  to  a  sufficient  degree  to  be  palpable  renders 
radical  operation  futile  in  the  vast  majority  of  instances,  and 
marked  infiltration  renders  a  case  positively  unfit  for  such  a 
procedure.  Minor  degrees  of  infiltration  and  fixation  of  the 
cervix  may  be  due  to  inflammatory  exudate  proceeding  ahead 
of  the  tumor,  and  on  the  grounds  that  the  disease  is  necessarily 
fatal  if  treated  in  a  conservative  manner,  that  if  recurrence  does 
take  place  the  horrible  odor  and  hemorrhage  may  be  lacking, 
when  in  doubt  one  always  inclines  toward  exploration  with  a 
view  to  radical  operation.  The  method  of  operation  should  be 
the  most  radical  that  is  possible,  and  a  brief  description  will  be 
found  in  Chap.  X,  but  so  extensive  a  dissection  should  not  be 
undertaken  by  any  but  the  most  expert  operators.  Ordinary 
vaginal  hysterectomy  does  not  permit  removal  of  the  tissue  ad- 
jacent to  the  uterus  and  should  be  reserved  for  cases  in  which  the 
disease  is  accidentally  discovered  at  a  very  early  date.  Schauta^s 
radical  vaginal  hysterectomy  offers  more  hope  than  vaginal 
hysterectomy  as  ordinarily  performed,  but  it  requires  even  more 
skill  than  the  extensive  abdominal  operation. 

Cases  not  Suitable  for  Radical  Operation. — Notwithstanding 
all  that  has  been  said  in  favor  of  early  diagnosis,  the  vast  major- 
ity of  all  cases  of  cancer  of  the  cervix  arrive  in  the  surgeon's 


PALLIATIVE  TREATMENT  OF  CARCINOMA  OF  THE  CERVIX      IQl 

hands  too  late  for  any  possibility  of  radical  operation  and  the 
various  palliative  measures  must  be  carefully  considered .  These 
consist  of  vaginal  hysterectomy,  high  amputation  of  the  cervix 
with  the  cautery,  extensive  destruction  with  the  cautery  by 
Percy^s  method,  and  radiotherapy. 

Vaginal  hysterectomy  may  be  chosen  when  infiltration  about 
the  cervix  is  trifling,  and  although  recurrence  at  the  site  of  opera- 
tion is  almost  certain  to  occur,  vaginal  hysterectomy  in  most  in- 
stances does  prevent  the  horrible  odor  and  hemorrhage  of  open 
ulceration  into  the  vagina.  In  view  of  the  fact  that  cauteri- 
zation seems  to  inhibit  the  growth  and  even  destroy  cancer  cells 
at  some  distance  from  the  primary  tumor,  the  Byrne  operation 
with  the  cautery  is  the  choice  in  most  instances  rather  than  vagi- 
nal hysterectomy.  In  late  cases  with  large  cauliflower  masses 
projecting  into  the  vagina,  or  deep  excavation  of  the  cervical 
tissue,  Percy's  method  appeals  to  the  author  as  the  most  satis- 
factory yet  devised,  and  further  experience  must  determine 
whether  it  is  not  appliable  to  early  cases  as  well. 

Sometimes  even  a  palliative  operation  is  not  advisable,  and 
this  is  true  when  the  growth  has  so  seriously  encroached  on  the 
bladder  or  rectum  that  any  interference  would  open  these  vis- 
cera and  produce  an  immediate  fistula. 

For  a  short  time  reports  of  cures  by  means  of  the  X-ray  gave 
rise  to  the  hope  that  an  adequate  means  for  dealing  with  inoper- 
able cervical  carcinoma  had  been  discovered.  At  present  less  is 
heard  of  this  and  more  of  the  possibiHties  inherent  in  destruction 
by  radium.  It  seems  to  have  been  demonstrated  beyond  ques- 
tion that  exposure  to  large  doses  of  radium  destroys  cancerous 
tissue  more  rapidly  than  it  does  the  normal  tissue  at  the  edge  of 
the  new  growth,  and  some  surprising  results  have  been  reported. 
Making  due  allowance  for  over-enthusiasm,  it  is  probable  that 
some  types  of  carcinoma  really  are  cured  by  radium,  and  any 
inoperable  case  should  be  given  the  benefit  of  this  treatment, 
providing  a  sufficient  quantity  of  radium  is  available  and  in  the 
possession  of  an  expert  in  its  use.     The  Kmitations  imposed  by 


192  DISEASES   AND   INJURIES    OF   THE    CERVIX 

the  small  amount  of  the  metal  in  existence,  and  the  extraordi- 
nary expense  attached  to  its  use  together  with  its  concentration 
in  a  few  hands,  renders  it  impossible  to  apply  it  at  all  extensively 
or  to  ascertain  the  permanency  of  reported  cures. 

When  treatment  of  any  kind  proves  ineffectual  and  even 
palliative  operation  is  without  avail,  keeping  the  parts  clean 
with  douches  of  i-iooo  permanganate  solution,  1-500  or  i-iooo 
formahn,  or  if  hemorrhage  is  a  marked  symptom,  tannic  acid  in 
I  per  cent,  solution  is  about  all  that  can  be  done  locally,  al- 
though many  other  methods  of  chemical  cauterization  and 
hardening  have  been  advocated.  Patients  who  are  the  victims 
of  hopeless  cancer  of  the  cervix  should  be  given  as  much  mor- 
phine as  is  demanded  for  the  pain,  not  only  to  reheve  the  latter 
but  to  promote  mental  comfort  and  quiet  that  apprehension 
which  is  so  invariable  an  accompaniment  of  the  disease. 

OPERATIONS  ON  THE  CERVIX 

Dilatation.^ — While  dilatation  of  the  external  uterine  orifice 
may  be  performed  in  the  ofhce,  dilatation  of  the  cervix  as  a 
whole  is  distinctly  not  an  office  operation.  Dilatation  of  the 
external  orifice  may  be  done  with  graduated  hard  rubber 
bougies  which  are  introduced  one  after  the  other  in  successively 
larger  sizes  as  is  done  in  the  passage  of  sounds  for  stricture  of 
the  male  urethra,  but  these  bougies  should  not  pass  the  internal 
orifice,  and  even  this  trifling  procedure  is  dangerous  if  the  patient 
has  cervical  gonorrhea  or  any  form  of  pelvic  inflammatory  dis- 
ease. The  bougies  should  be  steriUzed  by  prolonged  immersion 
in  strong  bichloride  solution,  and  every  effort  should  be  made  to 
secure  asepsis  of  the  external  uterine  orifice  and  cervical  canal. 
Rapid  dilatation  is  most  frequently  done  as  a  preliminary  to 
curettage  in  order  to  permit  the  easy  introduction  of  instru- 
ments through  the  cervical  canal.  It  is  also  of  some  temporary 
use  to  relieve  certain  types  of  dysmenorrhea.  Dilatation  of  the 
cervix  is  contra-indicated  if  acute  or  chronic  pelvic  inflammatory 


IMMEDIATE    REPAIR    OE    CERVICAL    LACERATION  1 93 

disease  is  present  or  if  acute  infection  of  the  cervical  mucosa 
exists. 

The  vagina  should  be  cleansed  by  first  scrubbing  it  with 
soap  and  water,  then  douching  with  sterile  water,  followed  by 
3^  of  I  per  cent,  creolin  or  lysol.  The  patient  should  be  anaes- 
thetized and  placed  in  the  lithotomy  position.  With  the 
perineum  retracted,  the  anterior  lip  of  the  cervix  is  grasped 
with  volsellum  forceps  and  steadied,  while  the  dilator  is  intro- 
duced through  the  internal  uterine  orifice.  Occasionally  it  will 
be  found  necessary  to  use  a  small  dilator  or  even  a  large  hsemo- 
stat  in  order  to  dilate  the  external  orifice  sufficiently  to  permit 
the  introduction  of  the  larger  instrument,  whose  blades  should 
expand  parallel  to  each  other.  Dilatation  should  be  made 
cautiously  until  the  resistance  of  the  cervical  tissue  is  thoroughly 
tested.  The  dilator  is  opened  as  far  as  can  be  done  easily  by 
hand  pressure  (not  by  the  screw  with  which  most  instruments 
are  provided),  held  for  a  short  time,  turned  into  another  quad- 
rant of  the  cervix,  opened  and  held  again,  and  so  continued 
until  the  canal  is  stretched  as  far  as  necessary.  The  dangers 
are  that  infectious  material  may  be  forced  into  the  cervical 
tissue  by  the  pressure  of  the  blades,  and  that  the  cervix  or 
lower  segment  of  the  uterus  may  be  ruptured.  The  former  can 
be  avoided  by  a  proper  selection  of  cases,  the  latter  by  using 
hand  pressure  only  and  that  cautiously  and  slowly,  never  by 
sudden  forcible  jumps  of  the  instrument. 

The  after-care  consists  only  of  rest  in  bed  for  two  or  three 
days. 

REPAIR   OF    CERVICAL   LACERATION 

Immediate  Repair. — For  reasons  previously  given  immediate 
repair  of  the  lacerated  cervix  is  indicated  only  in  case  a  deep 
injury  is  causing  severe  hemorrhage.  Aseptic  precautions 
should  be  most  pedantic.  No  preliminary  douches  are  re- 
quired as  the  vagina  is  presumed  to  be  aseptic  at  the  close  of 
labor,  and  anaesthesia  usually  is  unnecessary  and  a  waste  of 
13 


194  DISEASES    AND    INJURIES    OF   THE    CERVIX 

valuable  time.  The  vagina  is  held  open  with  retractors  and  the 
uterus  pushed  downward  by  an  assistant  who  makes  pressure 
upon  the  fundus,  while  the  cervical  lips  are  caught  with  vol- 
sellum  forceps  and  drawn  to  the  vulva.  The  bleeding  is 
materially  lessened  by  this  maneuver  alone.  Chromic  catgut 
sutures  are  used,  the  first  one  taking  up  the  tissues  above  the 
angle  of  the  tear.  This  stops  the  bleeding  at  once,  when  either 
interrupted  or  continuous  sutures  may  be  introduced  in  a  care- 
ful manner,  closing  the  injury  down  to  the  external  uterine 
orifice. 

Secondary  Repair,  Trachelorrehaphy.^ — Small  thin  cervical 
lips  are  essential  if  a  proper  secondary  repair  of  an  old  lacera- 
tion is  to  be  made.  If  the  patient  is  past  the  child-bearing  age 
or  the  cervix  is  much  hypertrophied,  amputation  is  the  pref- 
erable operation.  The  contra-indications  to  trachelorrhaphy 
are  pelvic  inflammatory  disease  and  acute  infection  of  the 
body  of  the  uterus  or  the  cervix  itself. 

The  patient  is  anaesthetized,  placed  in  the  lithotomy  position, 
and  the  vagina  cleansed  as  for  dilatation.  The  cervix  is  ex- 
posed by  perineal  retraction,  and  each  lip  is  caught  with  a  volsel- 
lum  forceps  at  the  exact  point  which  will  form  its  side  of  the 
new  external  orifice.  The  new  cervical  canal  is  next  outlined 
with  the  knife,  and  the  apex  of  the  tear  incised  at  either  side  of 
the  superior  end  of  the  new  canal.  The  strip  of  mucosa  which 
is  left  in  the  middle  of  either  flap  should  be  a  little  broader  than 
the  normal  canal,  and  its  termination  at  the  external  os  should 
be  wider  than  the  remainder,  so  that  when  the  lips  are  approxi- 
mated the  new  orifice  will  be  trumpet-shaped.  The  scar  tissue 
and  mucous  membrane  of  each  lip  on  both  sides  of  the  newly 
outlined  canal  are  then  removed  either  with  knife  or  scissors. 
Bleeding  is  free  but  rarely  needs  any  other  attention  than  the 
proper  placing  of  the  sutures. 

The  first  suture  on  either  side  should  enter  one  lip  on  the 
vaginal  mucosa,  emerge  on  the  mucosa  of  the  undenuded  strip 
of  the  same  lip,  re-enter  on  the  mucosa  of  the  undenuded  strip 


TRACHELORRHAPHY 


195 


Fig.  83. — Trachelorrhaphy.^    "The   new  cervical  canal  is  outlined 

with  the  knife." 


Fig.  84. — Trachelorrhaphy.    The  apex  of  the  tear  has-been  incised  on  both 
sides.    On  one  side  the  scar  tissue  is  in  process^of  removal. 


196  DISEASES   AND   INJURIES   OF   THE   CERVIX 

on  the  opposite  lip,  and  emerge  opposite  its  point  of  entrance. 
This  stitch  when  tied  should  lie  at  or  above  the  apex  of  the  denuda- 
tion. A  sufficient  number  of  stitches  should  be  introduced  to 
secure  approximation,  usually  three  or  four  on  each  side.  None 
of  the  sutures  should  bite  too  far  toward  the  center  of  the  strip 


Fig.  85. — Both  sides  denuded.     Stitches  hud  on  one  side.     New  external  os  will 

be  trumpet  shaped. 

of  mucosa  left  in  the  middle  of  the  lips,  for  while  permanent 
stenosis  could  not  result  if  this  were  done,  retention  of  uterine 
secretions  during  the  time  the  stitches  were  in  place  would  be 
certain  to  occur.  The  stitches  are  not  tied  until  all  are  in  place 
when  they  are  knotted  from  above  downward  snugly  enough 
to  assure  haemostasis,  but  no  tighter  than  is  necessary  for  this 


TRACHELORRHAPHY,    AFTER-CARE 


197 


purpose.  Suture  material  should  be  chromic  gut  if  perineal 
work  is  done  at  the  same  sitting;  if  not,  either  silkworm  gut, 
silver  wire,  or  chromic  gut  at  the  fancy  of  the  operator. 

After -care.^ — ^Rest  in  bed  for  eight  or  ten  days  is  judicious, 
although  it  is  not  likely  that  healing  would  be  disturbed  if  the 
patient  were  up  much  sooner.  No  douches  are  used  at  first  as 
they  serve  no  useful  purpose  and  may  be  the  source  of  infection. 


Fig.  86. — All  sutures  tied.     The  first  stitcli  in  each  side  is  "tied  above  the  apex 

of  denudation." 


If  chromic  catgut  has  been  used  the  discharge  becomes  rather 
irritating  after  five  or  six  days  and  saline  or  boric  acid  douches 
are  necessary.  If  these  are  carefully  given  in  an  aseptic  manner 
there  is  no  risk  of  infection  after  this  time. 

Secondary  hemorrhage  is  more  common  after  repair  or 
amputation  of  the  cervix  than  after  any  other  operation  upon 
the  female  genitalia,  and  this  is  due  to  imperfect  placing  of  the 
first  stitch.  Should  hemorrhage  occur  the  proper  treatment  is 
the  introduction  of  a  suture  high  enough  on  the  lateral  wall  of 


1 98 


DISEASES   AND   INJURIES   OF   THE   CERVIX 


the  cervix  to  control  the  circular  artery.  Excessive  menstrua- 
tion at  the  first  period  after  operation  is  also  common,  and  it  is 
a  wise  precaution  to  advise  rest  in  bed  at  this  time. 


Fig.  87. — Modified  Schroeder  amputation  of  cervix  for  erosion  or  laceration. 
Line  of  incision  which  splits  the  cervix. 


AMPUTATION    OF    THE    CERVIX 


Schroeder^s  Amputation  and  Its  Modification. — The  Schroeder 
amj)utation  of  the  cervix  is  limited  in  its  indications  to  in- 
tractable cases  of  endocervicitis,  but  by  a  trifling  modification 


SCHROEDER  AMPUTATION   OF    THE    CERVIX 


199 


it  becomes  the  most  appropriate  operation  for  those  cervical 
lacerations  in  which  amputation  is  preferable  to  repair. 

In  the  Schroeder  amputation  the  cervix  is  split  by  an  incision 


Fig.  88. — Modified  Schroeder.     The  cervix  has  been  split  and  the  lips  are  held 

widely  apart. 


which  extends  transversely  across  its  inferior  extremity,  and 
which  penetrates  deeply  enough  to  expose  all  the  diseased 
mucosa  when  the  lips  are  held  widely  apart.  At  the  bottom 
of  this  incision  a  cut  is  made  upon  each  lip  of  sufficient  depth 


200 


DISEASES   AND    INJURIES    OF    THE    CERVIX 


to  penetrate  the  mucosa  and  at  right  angles  to  the  first  inci- 
sion. A  thin  shaving  is  then  spht  from  the  internal  surface  of 
each  lip.  This  shaving  includes  all  the  cervical  mucosa  inferior 
to  the  last  incision  and  some  of  the  cervical  tissue  at  either 


Fig.  89. — Modified  Schroeder.     At  the  bottom  of  the  first  incision  a  cut  has 
been  made  upon  each  lip  "at  right  angles  to  the  first  incision." 


side  of  the  canal.  The  cervical  lips  are  then  stitched  in  such 
fashion  as  to  make  a  new  canal  lined  by  squamous  epithehum. 
This  is  done  by  infolding  them  by  passing  a  suture  from  the 
center  of  each  lip  to  the  stump  of  cervical  mucosa  left  high  in 
the  wound,  and  thereafter  applying  a  sufficient  number,  usually 


SCHROEDER  AMPUTATION  OF   THE   CERVIX 


20I 


two  or  three  to  each  hp,  to  encircle  the  entire  canal.  When 
this  is  done  a  small  wound  remains  on  each  side  of  the  cervix 
and  this  is  closed  by  one  or  two  sutures. 

A  modification  by  which  the  operation  becomes  applicable 


Fig.  90. — Modified  Schroeder.     "  A  thin  shaving  is  then  split  from  the  internal 
surface  of  each  lip."     This  shaving  may  be  wedge  shaped,  base  downward. 


to  deep  laceration  with  hypertrophy,  consists  in  making  the 
shaving  which  contains  the  cervical  mucosa  wedge-shaped,  the 
base  of  the  wedge  being  taken  from  the  inferior  end  of  each  hp. 
The  wedge  should  be  as  thick  as  necessary  in  the  individual 
case,  and  in  greatly  hypertrophied  cervices  may  include  all  of 


202 


DISEASES   AND   INJURIES    OF   THE    CERVIX 


each  lip  up  to  the  attachment  of  the  vaginal  wall.  The  sutures 
are  passed  in  the  manner  above  described  and  are  intended  to 
so  reconstruct  the  cervical  canal  as  to  cover  all  raw  surfaces 


Fic.  91. — Modified  Schroeder.     The  cervical  lips  are  infolded  to  meet  the  mucosa 
of  the  cervical  canal  by  sutures  which  are  here  shown  laid  but  not  tied. 


with  squamous-celled  mucosa.  If  bleeding  is  free,  the  highest 
stitch  on  cither  side  should  include  a  deep  bite  of  cervical  tissue. 
Circular  Amputation. — Circular  amputation  is  preferred  for 
hypertrophic  elongation  of  the  cervix  and  for  the  supra-vaginal 
elongation  which  occurs  in  prolapse  of  the  uterus. 


CIRCULAR  AMPUTATION  OF   THE   CERVIX  203 

After  drawing  the  cervix  down  its  junction  with  the  vaginal 
wall  is  noted,  and  at  this  point  a  circular  incision  is  made  which 


Fig.  92. — Modified  Schroeder.  The  stitches  reconstructing  the  cervical 
canal  are  tied.  A  small  wound  remains  on  each  side  through  which  sutures  are 
shown  not  tied. 

extends  through  the  mucosa  and  down  to  muscular  tissue.     The 
cervix  is  steadied  by  traction,  while  the  vaginal  wall  is  separated 


204  DISEASES   AND   INJURIES    OF   THE    CERVIX 

from  it  by  pushing  off  its  connective-tissue  attachments  as  far 
as  necessary,  all  pressure  being  directed  against  the  cervix.     The 


Fig.  93. — Modified  Schroeder.     All  sutures  tied.     The  last  one  at  each  side  is 
tied  above  the  apex  of  denudation  in  order  to  certainly  control  hemorrhage. 

bladder  may  be  pushed  off  anteriorly  if  it  is  desirable  to  ampu- 
tate very  high.     The  cervix  is  now  removed  by  a  transverse  cut 


CIRCULAR  AMPUTATION   OF   THE   CERVIX 


205 


which  at  first  passes  through  the  anterior  half  of  the  cervix  only, 
as  the  stump  retracts  and  is  sutured  with  difficulty  if  the  incision 


Fig.  94. — Circular  amputation  of  cervix.     An  incision  is  made  at  the  junction  of 
"the  vaginal  and  cervical  mucosa  which  encircles  the  cervix.     Anterior  view. 

extends  completely  through  it.     One  or  two  sutures  are  now 
introduced  which  unite  the  vaginal  and  cervical  mucosa.    These 


2o6 


DISEASES   AND   INJURIES   OF   THE   CERVIX 


are  passed  deeply  in  order  to  control  hemorrhage.     The  pos- 
terior half  of  the  cervix  is  now  removed  while  the  stump  is  held 


Fig.  95. — Circular  amputation  of  cervix.     An  incision  is  made  at  the  junction 
of  the  vaginal  and  cervical  mucosa.     Posterior  view. 

by  the  sutures  already  introduced,  and  a  similar  set  is  laid  on 
the  posterior  half. 

Stitches  are  now  introduced  from  vaginal  to  cervical  mucosa 
around  the  circumference  of  the  cervix,  and  are  tied  after  all 


CIRCULAR  AMPUTATION  OF   THE   CERVIX 


207 


are  in  place.     Owing  to  the  redundance  of  vaginal  wall  there 
is  a  marked  puckering  of  the  margins  and  the  completed  opera- 


FiG.  96. — Circular  amputation  of  cervix.  The  cervix  is  now  removed  by  a 
transverse  cut  which  passes  through  its  anterior  half  only  and  one  or  two  sutures 
are  introduced  from  vaginal  to  cervical  mucosa. 

tion  has  an  unfinished  appearance  which,  however,  smoothes 
out  and  disappears  after  healing  is  complete. 


2o8 


DISEASES   AND   INJURIES    OF   THE    CERVIX 


Amputation  with  the  Cautery.— This  operation  is  done  for 
malignant  disease,  and  is  feasible  only  with  the  heavier  electric 


Fig.  97. — Circular  amputation  of  cervix.     The  posterior  half  is  now  removed 
while  the  stump  is  held  by  the  sutures  already  introduced. 


cautery  knives  as  the  ordinary  PaqueHn  cools  too  quickly  to  do 
good  work. 


AMPUTATION  WITH  THE  CAUTERY 


209 


Any  redundant  masses  of  new  growth  which  obscure  the 
view  are  cut  away,  and  the  cervix  is  then  amputated  as  close  to 
the  surrounding  tissue  as  it  is  possible  to  go  without  entering  the 


Fig.  98. — Circular  amputation  of  cervix.     Stitches^are'^now  introduced  to  com- 
plete the  new  cervical  canal  and  close  the  gaps  at  either  side. 

peritoneal  cavity,  bladder,  or  rectum.     The  amputation  should 
go  high  into  the  uterus,  and  when  completed  the  excavation 
left  is  cone-shaped,  base  downward. 
14 


210 


DISEASES   AND   INJURIES   OF   THE   CERVIX 


The  cautery  blade  should  be  kept  at  a  dull  cherry  red  heat, 
at  which  temperature  the  hemorrhage  usually  is  trivial.     If  a 


Fig.  99. — Circular  amputation  of  cervix.     All  stitches  tied.     The  two   most 
external  are  tied  above  the  apex  of  denudation. 

bleeding  point  persists,  pressure  is  made  upon  it  with  the  heat 

lessened,  and  it  is  only  rarely  that  a  suture  or  ligature  is  needed. 

If  the  uterus  cannot  be  drawn  well  out  of  the  vagina,  extreme 


CURETTE  AND  CAUTERY  211 

care  is  needed  to  avoid  burning  the  vulva  and  vaginal  walls, 
and  with  the  heavier  cauteries  a  water-cooled  speculum  is  al- 
most a  necessity.  The  cavity  left  after  amputation  should  be 
loosely  packed  with  iodoform  gauze  which  is  allowed  to  remain 
for  four  or  five  days,  after  which  it  is  removed  and  deodorizing 
douches  used  as  the  slough  produced  by  the  burn  becomes 
detached  and  comes  away. 

Curette  and  Cautery. — This  operation  has  been  used  exten- 
sively as  a  palliative  measure  in  cases  of  cervical  carcinoma  in 
which  radical  operation  was  out  of  the  question,  but  it  bids  fair 
to  be  superseded  by  massive  cauterization  as  devised  by  Percy 
because  the  latter  requires  no  cutting,  and  most  surgeons  of 
wide  experience  question  the  wisdom  of  opening  any  surfaces 
for  absorption  as  is  bound  to  be  done  when  cutting  instruments 
are  used.  In  any  event  the  curette  and  cautery  should  be 
reserved  for  those  cases  in  which  the  predominant  indication  is 
to  relieve  overwhelming  fetor,  and  no  idea  is  to  be  entertained 
either  of  cure  or  prolongation  of  life  by  this  procedure. 

A  large  sharp  curette  is  used  to  separate  and  remove  all  friable 
tissue  until  the  instrument  impinges  upon  the  firm  structures 
underlying  it.  During  this  step  the  bleeding  is  free  and  it  is 
therefore  desirable  to  complete  it  as  rapidly  as  possible.  After 
this  is  finished  the  dome-shaped  cautery  is  applied  to  the  raw 
surface  until  it  is  thoroughly  charred  and  bleeding  has  ceased. 
The  procedure  may  end  at  this  time,  or,  preferably,  the  cau- 
terization may  be  continued  by  the  application  of  zinc  chloride. 
For  this  purpose  a  small  tampon  is  soaked  in  a  50  per  cent,  solu- 
tion, squeezed  dry,  and  inserted  into  the  crater  left  by  the  opera- 
tion. The  vagina  is  immediately  filled  with  gauze  wet  in  a 
strong  solution  of  bicarbonate  of  sodium  which  neutralizes  any 
excess  of  the  zinc  salt  and  prevents  its  coming  into  contact  with 
the  vaginal  walls  or  vulva.  The  vaginal  dressing  should  be 
removed  in  24  to  48  hours  and  the  tampon  allowed  to  remain 
until  it  becomes  loose,  which  usually  requires  a  week  or  10 
days.     Traction  upon  the  thread  which  is  left  attached  when 


212  DISEASES   AND   INJURIES    OF   THE   CERVIX 

the  tampon  is  introduced  brings  away  the  tampon  and  a  cast 
of  the  tissue  to  which  it  has  been  appHed.  Moderate  pain  is 
present  for  a  day  or  two,  but  not  more  than  is  easily  borne. 
After  removal  of  the  tampon  antiseptic  and  deodorizing  douches 
should  be  used,  and  in  very  favorable  cases  the  walls  of  the 
entire  cavity  become  covered  with  healthy  granulations  which 
cicatrize  and  leave  only  a  pit  in  the  vaginal  vault. 

The  same  caution  is  necessary  as  in  amputation  to  see  that  the 
peritoneal  cavity  or  neighboring  viscera  are  not  penetrated. 

Massive  Cauterization. — Encouraged  by  the  results  obtained 
by  amputation  with  the  cautery,  Percy  of  Galesburg,  Illinois, 
has  developed  a  method  of  massive  cauterization  which  is  based 
upon  the  ease  with  which  cancer  cells  are  destroyed  by  a  mod- 
erate degree  of  moist  heat.  The  cautery  iron  itself  apphes 
only  dry  heat  but  the  tissue  juices  near  the  iron  are  converted 
into  steam,  while  those  at  some  distance  are  sufficiently  heated 
to  retard  or  destroy  the  cancer  cells  in  their  vicinity.  Complete 
details  of  this  method  can  be  found  in  articles  in  the  Journal 
of  the  American  Medical  Association  and  other  journals  men- 
tioned in  the  references.  The  salient  points  briefly  are  as 
follows:  Two  operators  are  required,  one  to  open  the  abdomen 
and  the  other  to  handle  the  cautery. 

After  preliminary  sterilization  of  the  anterior  abdominal 
wall,  the  abdomen  is  opened  through  a  median  incision  and  all 
coils  of  intestine  removed  from  the  pelvis  and  held  in  the  upper 
abdomen  by  pads.  The  operator  who  opens  the  abdomen  then 
turns  his  attention  to  the  degree  of  heat  which  the  vaginal 
operator  now  applies  by  means  of  cautery  irons  kept  hot  by  an 
electrical  device.  Before  these  are  used  a  water-cooled  specu- 
lum is  introduced  into  the  vagina  which  effectually  prevents 
burning  of  the  vulva  or  vaginal  walls. 

The  cautery  is  applied  to  the  cancerous  tissue  in  the  vaginal 
vault  by  holding  the  iron  against  each  portion  of  it,  while  the 
fingers  of  the  abdominal  assistant  are  kept  in  contact  with  the 
peritoneum  covering  the  abdominal  surface  of  the  same  area. 


MASSIVE   CAUTERIZATION,   PERCY 


213 


Cauterization  is  continued  at  each  point  to  which  the  iron  is 
apphed  until  the  fingers  in  the  abdomen  are  distinctly  un- 
comfortable when  it  is  shifted  to  another  locality,  and  this  is 
continued  until  the  uterus  and  infiltrated  parametrium  are 
converted  into  a  thin-walled,  freely  mobile  sac. 


Fig.  100. — Massive  cauterization  by  Percy  method.  Sagittal  section.  The 
fingers  of  the  abdominal  assistant  are  held  in  contact  with  the  peritoneum 
covering  the  area  attacked  through  the  vagina  by  the  cautery. 


If  the  infiltration  extends  toward  the  bladder  wall,  a  ther- 
mometer is  introduced  through  the  urethra  to  indicate  the  limit 
of  safety  in  that  direction  which  is  approximately  i5o°F. 

Modifications  of  the  operation  are  devised  for  extensive  intra- 
abdominal involvement.     In  these  a  water-cooled  speculum  is 


214 


DISEASES   AND   INJURIES   OF   THE   CERVIX 


passed  through  the  incision  into  the  abdominal  cavity  and  the 
cautery  applied  directly  to  the  peritoneal- covered  surface. 
This  cannot  be  recommended  until  more  experience  has  been 
gained,  and  in  fact  it  is  better  for  the  beginner  to  be  care- 
ful not  to  produce  ureteral,  vesical,  or  rectal  fistulae  until  the 


Fig.  ioi. — Massive  cauterization  by  Percy  method,  water  cooled  speculum. 
Cautery  iron  applied  to  cancerous  area. 


method    has   obtained    acceptance    as   a   recognized  surgical 
procedure. 

Aside  from  a  moderate  dose  of  narcotic  no  general  or  local 
after-treatment  is  used  and  the  patient  is  treated  as  any  other 
abdominal  section  might  be. 


REFERENCES  215 

Percy  has  recently  called  attention  to  the  fact  that  this  pro- 
cedure is  most  effectual  when  the  cautery  is  not  sufficiently 
hot  to  cause  charring,  carbonization  markedly  retarding  the 
diffusion  of  heat  from  the  cautery  head  through  the  tissues. 

The  proper  carrying  out  of  this  operation  necessitates  pro- 
longed anaesthesia,  from  one  to  two  hours,  but  aside  from  this 
the  operation  seems  to  present  but  little  immediate  danger, 
although  late  secondary  hemorrhage  may  be  profuse  enough 
to  jeopardize  life. 

REFERENCES 

BYRNE,  J. — Clinical  Notes  on  the  Electric  Cautery  in  Uterine  Surgery.     Wm. 

Wood  &  Co.,  N.  Y.,  1873. 
ZOMAKION. — Ein  barter  Schanker  der  Portio-vaginalis  uteri  und  seine  Diag- 

nostik.     Arch.  f.  Dermat.  u.  Syph.,  1913,  cxvi,  329. 
HUNNER.— The     Treatment     of    Leucorrhea     with     the     Actual    Cautery. 

J.  A.  M.  A.,  1906,  xlvi,  191. 
BONNEY. — The   Bearings  of  Pathology  on  the  Prevention,   Diagnosis,   and 

Surgical  Cure  of  Carcinoma  of  the  Cervix.    Practitioner,  1909,  Ixxxi,  737. 
BOSSI,  L.  M. — Die  wahre  Prophylaxe  des  Uteruskrebses  Ein  Mahnruf  an  die 

Gynakologen.     Zentralh.f.  Gyn.,  1913,  xxxvii,  1000. 
KELLY  AND  NEEL. — Carcinoma  of  the  Cervix  of  the  Uterus.     Johns  Hopkins 

Hasp.  Bull.,  1913,  xxiv,  231. 
SCHICKELE. — Klinische  und  topographischanatomische  Studien  ueber  Cer- 

vixmyome.     Ztschr.f.  Geh.  u.  Gyn.,  1914,  Ixxv,  684. 
RABINOVITZ.— Myoma  of  the  Cervix  Uteri.     Surg.,  Gyn.  ^  Obst.,  191 2,  xv,  668. 
VERTES  AND  ZACHER.— Das  Sarkom  des    Gebarmutterhalses.     Zeitsch,  f. 

Geh.  und  Gyn.,  1912,  Ixx,  171. 
JELLETT,  H.— Adenocarcinoma  of  the  Cervix.     Tr.  Roy.  Acad.  Med.,  Ireland, 

1911,  xxix,  426. 
STEIN",  A. — Carcinosarcoma  uteri  mit  Metaplasie  des  Zylinderepithelkarzinom, 

Plattenepithelkarzinom.     Monats.  f.  Geh.  und  Gyn.,  191 2,  xxxvi,  417. 
LIEGNER. — Zur  Histologie  des  Carcinoma  cervicis  Uteri.     Beitr.  zu.  Geh.  ung. 

Gyn.,  1913,  xviii,  329. 
OBATA. — Statistischer  Beitrag  zur  Morphologie  des  Utemscarcinoms.     Arch. 

f.  Gyn.,  1913,  xcix,  474. 
THEILHABER.— Zur  Lehre  Von  den  Ursachen  und  der  Behandlung  der  Carcin- 

ome  der  weiblichen  Genitalen.     Arch.  f.  Gyn.,  1912,  xcvi,  561. 
THEILHABER  UND  EDELBERG.— Die  Beziehungen  der  Fortpflanzungsvor- 

gange  zu  den  Geschwulsten  der  weiblichen  Geschlechtsorgane.     Arch.  f. 

Gyn.,  191 2,  xcvi,  23. 


2l6  DISEASES   AND   INJURIES    OF    THE    CERVIX 

KAMPERMAN.— A  Study  of  Two  Hundred  and  Twelve  Cases  of  Cancer  of 

the  Uterus  with  Special  References  to  Early  Diagnosis.     Am.  J.  Obst., 

191 2,  Ixvi,  596. 
PETERSON.— Primary   and    End   Results   of   Fifty-one   Radical   Abdominal 

Operations  for  Cancer  of  the  Uterus.     Surg.,  Gyn.  b"  Obst.,  1912,  xv,  135. 
NEEL. — Results  after  the  Wertheim  Operation  for  Carcinoma  of  the  Cervix 

of  the  Uterus.     Trans.  Am.  Gyn.  Soc,  191 2,  xxxvii,  345. 
COBB. — Cancer  of  the  Uterus;  the  Operable  Cases;  the  Operation  of  Choice. 

Boston  M.  &*  S.  J.,  191 2,  clxvii,  37. 
KELLY  AND  NEEL. — Cauterization  of  "Inoperable"  Carcinoma  of  the  Cervix 

of  the  Uterus.     Johns  Hopkins  Hasp.  Bull.,  1913,  xxiv,  372. 
GELLHORN. — The  Extended  Vaginal  Operation  for   Cancer  of  the   Cervix 

Uteri.     Surg.,  Gyn.  bj°  Obst.,  1913,  xvi,  284. 
SCHAUTA. — Bericht  iiber  das  elfte  Beobachtungsjahr  der  erweiteren  vaginalen 

Krebsoperation.     Monats.  f.  Geb.  und  Gyn.,  1912,  xxxvi,  202. 
BAINBRIDGE. — Arterial  Ligation,  with  Lymphatic  Block  in  the  Treatment  of 

Advanced  Cancer  of  the  Pelvic  Organs.     Am.  J.  Obst.,  1913,  Ixviii,  649. 
C  HERON,  RUBENS  AND  DUVAL.— Der  Wert  der  Radiumbehandlung  des 

Gebarmutter   und    Scheidenkrebses.     Strahlentherap.,    1914,    v,    80;  Abst. 

Int.  Abst.  Surg.,  July,  1915. 
LAHM. — Ueber  den  Einfluss  von  Radium-Mesothorium  bestrahlung  auf  das 

Cervixkarzinom.     Monats.  f.  Geb.  und  Gyn.,  1914,  xxxix,  279. 
SCHAUTA. — Die  bisherigen  Erfahrungen  der  1  Frauenklinik  mit  Radium  and 

Mesothorium  bei  Krebs.     Wien.  med.  Woch.,  1913,  Ixiii,  2953. 
SCHAUTA. — Radium    und    Mesothorium    bei  Carcinoma  Cervices.     Monats. 

f.  Geb.  u.  Gyn.,  1913,  xxxviii,  503;  Abst.  Int.  Abst.  Surg.,  June,  1914. 
KEITLER. — Zur    Radiumbehandlung    des    Gebarmutterkrebses.     Wien.    klin. 

Woch.,  1913,  xxvi,  1839;  Abst.  Int.  Abst.  Surg.,  June,  19 14. 
WERTHEIM. — Radiumbehandlung     des     Gebarmutterkrebses.     Wien.     klin. 

Woch.,  1913,  xxvi,  1648. 
PINKUSS,  A. — Ueber  die  Erfolge  der  Mesothoriumbestrahlung  bei  Carcinom. 

Berl.  klin.  Woch.,  1913,  1,  1105;  Abst.  Int.  Abst.  Surg.,  Dec,  1913,  652. 
DEGRAIS  UND  BELLOT.— Uteruskrebs  und  Radium.    Strahlentherap.,  19 14, 

V,  102;  Abst.  Int.  Abst.  Surg.f  July,  19 15. 
BYRNE,  J. — Rules  to  be  Observed  in  Performing  High  Amputation  and  Other 

Operative    Measures   for    Cancer   of    the    Uterus    by    Galvano    Cautery. 

Brooklyn  M.  J.,  1892,  vi,  760. 
BYRNE,  J. — Vaginal  Hysterectomy  and  High  Amputation,  or  Partial  Extirpa- 
tion by  Galvano  Cautery  in  Cancer  of  the  Cervix  Uteri.     An  Inquiry  into 

their  Relative  Merits.     Brooklyn  M.  J.,  vi,  729. 
NEWMAN. — Surgery  of  the  Cervix  Uteri.     Surg.,  Gyn.  6*  Obst.,  191 2,  xv,  39. 
GELLHORN. — A  New  Mode  of  Treatment  for  Inoperable  Cancer  of  the  Uterus 

by  Means  of  Acetone.     /.  A.  M.  A.,  1907,  xlviii,  1400. 
LEONARD. — The    Post-operative  Results  of  Trachelorrhaphy  in  Comparison 

with  Those  of  Amputation  of  the   Cervix.     Surg.,  Gyn.  &*  Obst.^   1914, 

xviii,  35. 


REFERENCES  21 7 

BONNEY. — On  the  Technique  of  Amputation  of  the  Vaginal  Cervix.  /.  ObsL 
b°  Gyn.  Brit.  Efnp.,  1913,  xxiii,  121. 

LEONARD. — Post-operative  Results  of  Amputation  of  the  Cervix.  Surg., 
Gyn.  b"  Obst.,  1913,  xvi,  390. 

PERCY.— The  Result  of  the  Treatment  of  Cancer  of  the  Uterus  by  the  Actual 
Cautery,  with  a  Practical  Method  for  Its  Application.  /.  A.  M.  A.,  191 2, 
Iviii,  696. 

PERCY. — A  Method  of  Applying  Heat  Both  to  Inhibit  and  Destroy  Inoperable 
Carcinoma  of  the  Uterus  and  Vagina.     Surg.,  Gyn.  6^  Ohsl.,  1913,  xvii,  371. 

PERCY. — The  Treatment  of  Inoperable  Carcinoma  of  the  Uterus  by  Applica- 
tion of  Heat.     Surg.,  Gyn.  &°  Obst.,  1914,  xix,  452. 


CHAPTER  VIII 
DISEASES  OF  THE  UTERINE  BODY 

Endometritis. — Under  this  heading  are  classed  a  number  of 
dissimilar  diseases,  and  a  variety  of  symptoms  are  incorrectly 
regarded  as  evidence  of  the  presence  of  endometritis. 

In  the  following  discussion  an  attempt  will  be  made  to  classify 
endometritis  from  a  clinical  standpoint  and  to  state  briefly  the 
pathology  and  symptoms  of  the  clinical  types,  although  it  is 
certain  that  the  pathological  findings  and  clinical  symptoms 
often  fail  to  agree. 

Acute  Endometritis. — Acute  non-puerperal  inflammation  of 
the  endometrium  may  occur  during  the  progress  of  certain 
specific  systemic  diseases  such  as  scarlatina,  it  may  be  produced 
by  the  invasion  of  any  of  the  pyogenic  cocci,  and  most  fre- 
quently is  caused  by  the  gonococcus  of  Neisser. 

It  is  not  known  whether  the  ordinary  pyogenic  organisms  can 
attack  the  intact  endometrium  or  whether  an  abrasion  or  injury 
to  the  mucosa  is  necessary,  but  it  is  certain  that  gonorrhea  most 
frequently  extends  directly  upward  from  the  cervical  canal  to 
the  uninjured  mucosa  of  the  uterine  body. 

The  ordinary  type  of  acute  suppression  of  menstruation 
which  follows  exposure  to  cold  and  wet  and  is  succeeded  by  a 
profuse  flow  probably  is  an  acute  congestion,  and  it  is  not  known 
whether  micro-organisms  play  any  part  in  its  production. 

Puerperal  endometritis  is  a  subject  by  itself  and  does  not 
concern  us  at  the  present  time. 

In  the  non-puerperal  form  due  to  staphylococci,  streptococci, 
etc.,  the  germs  gain  entrance  to  the  uterine  cavity  through 
the  use  of  unclean  instruments  such  as  the  uterine  sound  or 
dilator,  and  occasionally  through  the  introduction  of  unclean 

218 


ACUTE   ENDOMETRITIS  219 

solutions  used  for  vaginal  douching,  the  tip  of  the  nozzle  being 
accidentally  pushed  into  the  cervical  canal. 

While  instrumentation  is  not  necessary  for  the  introduction 
of  gonococci,  they  may  be  implanted  on  the  endometrium  of  the 
body  by  instruments  which  are  passed  through  an  infected 
cervix  and  above  the  internal  uterine  orifice. 

Acute  non-puerperal  endometritis  is  itself  an  insignificant 
disease  but  its  complications  may  be  of  grave  importance. 

The  type  due  to  exposure  subsides  spontaneously  in  a  few 
days  as  does  that  associated  with  the  general  infections,  but 
gonorrheal  endometritis  almost  invariably  extends  to  the  tubes, 
while  ordinary  pyogenic  infection  may  result  in  ovarian  abscess, 
local  peritonitis,  general  peritonitis,  or  virulent  septicaemia. 

Pyogenic  endometritis  in  the  non-puerperal  uterus  is  not  so 
disastrous  as  is  the  same  disease  in  the  puerperal  uterus,  the 
raw  surface  and  large  vessels  and  lymphatics  of  the  latter  pre- 
senting a  much  more  favorable  opportunity  for  widespread 
dissemination. 

Pathology. — The  pathological  picture  in  acute  endometritis  is 
that  of  any  acute  inflammatory  condition  of  a  mucous  mem- 
brane; round-cell  infiltration  and  thickening  of  the  interstitial 
tissue,  with  widespread  separation  of  the  glandular  structures. 

Symptoms. — Sudden  suppression,  should  the  patient  be  men- 
struating, followed  by  a  prolonged  rather  profuse  flow  asso- 
ciated with  sub-acute  pelvic  pain,  is  the  predominating  symptom. 
Leucorrhea  may  not  be  present  at  first  but  follows  soon  after 
the  subsidence  of  the  earliest  symptoms.  If  the  inflammation 
is  due  to  gonorrheal  or  pyogenic  infection  the  leucorrhea  is 
purulent  and  may  be  blood-stained.  Otherwise  it  is  due  to 
hypersecretion  of  the  uterine  glands  and  is  serous  in  character. 
The  temperature  is  but  slightly  elevated  in  mild  cases  and 
reaches  a  high  point  only  in  the  more  serious  infections. 

Palpation  shows  some  tenderness  over  the  lower  abdomen, 
and  the  uterus  is  sensitive  to  the  touch  upon  digital  or  bi-manual 
examination.     In  severe  cases  it  may  be  difficult  or  impossible 


220  DISEASES    OF   THE   UTERINE  BODY 

to  distinguish  between  the  symptoms  produced  by  acute  endo- 
nietritis  and  those  caused  by  its  compHcations,  and  indeed  this 
differentiation  is  unnecessary,  endometritis  itself  being  an 
evanescent  affair  and  losing  its  importance  when  complications 
occur.  The  symptoms  of  acute  salpingitis,  oophoritis,  and  pel- 
vic peritonitis  are  frequently  mistaken  for  those  of  endome- 
tritis, and  they  can  be  ruled  out  only  by  a  careful  bi-manual  ex- 
amination in  which  all  the  pelvic  structures,  aside  from  the 
uterus,  are  found  to  be  normal. 

Treatment. — ^Local  treatment,  that  is,  treatment  applied 
directly  to  the  interior  of  the  uterus,  is  distinctly  contra- 
indicated.  Rest  in  bed  is  the  first  essential,  and  if  it  is  quite 
certain  that  the  peritoneum  is  not  involved  a  saline  cathartic 
should  be  administered.  Small  doses  of  Dover^s  powder  com- 
bined with  phenacetin  or  aspirin  relieve  the  discomfort,  and 
either  hot  or  cold  applications  may  be  made  to  the  lower  ab- 
domen. Sometimes  an  ice-bag  and  at  others  a  poultice  affords 
relief,  and  in  the  present  state  of  our  knowledge  the  sensations 
of  the  patient  are  the  only  criteria  by  which  we  may  decide 
which  is  the  better. 

Very  prolonged  hot  douches  are  usually  comforting,  but  it  is 
somewhat  paradoxical  to  apply  an  ice-bag  over  the  fundus  and 
hot  water  to  the  cervix. 

Perhaps  as  good  a  rule  as  any  is  to  use  cold  applications  to 
the  abdomen  at  the  outset,  and  change  to  warm,  together  with 
hot  douches,  as  the  temperature  subsides  and  the  symptoms 
abate. 

Chronic  Endometritis. — Chronic  endometritis  may  be  divided 
into  two  clinical  forms,  the  purulent  and  the  hemorrhagic. 

Chronic  purulent  endometritis  of  the  body  of  the  uterus  is 
a  rare  occurrence  but  it  sometimes  follows  an  acute  attack  which 
was  due  to  pyogenic  infection.  Uncomplicated  chronic  endome- 
tritis of  the  uterine  body  of  gonorrheal  origin,  is  almost  un- 
known, the  greater  number  of  cases  so  diagnosed  being  either 
gonorrheal  endocervicitis  or  gonorrheal  salpingitis. 


CHRONIC   ENDOMETRITIS  221 

The  most  prominent  symptom  is  indicated  by  the  name,  a 
discharge  of  pus  from  the  cavity  of  the  uterus.  In  association 
with  this  there  may  be  some  pain  and  pelvic  discomfort  and  also 
some  disturbance  of  menstruation,  but  the  purulent  discharge 
is  the  predominant  symptom.  In  order  to  ascertain  the  origin 
of  the  discharge  the  Schulze  tampon  may  be  used.  This  is 
made  like  the  ordinary  tampon  except  that  the  string  is  tied  in 
both  directions.  The  tampon  should  be  appHed  dry  and  with 
the  crossing  of  the  threads  directly  under  the  external  orifice 
of  the  uterus.  Examination  of  the  tampon  after  it  has  been 
in  place  24  hours  will  show  a  thin  sero-pus  or  pus  alone  if  the 
discharge  is  corporeal,  but  pus  intimately  mixed  with  mucus 
if  the  discharge  is  cervical.  The  uterine  discharge  is  at  the 
mid-portion  of  the  tampon,  any  excess  of  vaginal  secretion 
being  found  at  its  edges. 

Before  the  diagnosis  of  uncomplicated  chronic  endometritis 
can  be  established,  a  careful  bi-manual  examination  must  have 
ruled  out  any  possible  inflammatory  disease  of  the  tubes  or 
ovaries. 

Treatment. — Local  applications  to  the  uterine  cavity  un- 
doubtedly will  cure  chronic  purulent  endometritis  if  persisted 
in  for  a  sufficient  time.  AppHcations  strong  enough  to  be  of 
service  are  frequently  productive  of  severe  uterine  colic,  and 
the  risk  of  introducing  other  and  more  virulent  infection  is  so 
great  that  the  office  treatment  of  chronic  endometritis  is  fully 
as  serious  as  the  disease  itself. 

N on-gonorrheal  chronic  purulent  endometritis  should  be 
treated  by  curettage.  Gonorrheal  endometritis  is  so  frequently 
complicated  by  salpingitis  that  treatment  of  the  uterine  infec- 
tion is  of  minor  importance,  and  if  salpingitis  is  not  already 
present,  curetting  is  more  than  likely  to  be  followed  by  its  oc- 
currence within  two  or  three  days  after  the  operation. 

Hemorrhagic  Endometritis. — This  term  is  purely  cHnical  and 
is  used  to  cover  certain  types  of  disease  of  the  uterine  mucosa 
which  are  productive  of  hemorrhage.     At  least  one  of  them  is 


222 


DISEASES   OF   THE  UTERINE  BODY 


not  of  infectious  or  inflammatory  origin  and  micro-organisms 
are  conspicuous  by  their  absence,  so  that  the  term  endome- 
tritis" is  a  misnomer,  but  common  usage  has  so  sanctioned  it 
that  it  seems  necessary  to  retain  the  word  in  order  not  to  be 
misunderstood. 


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Fig.  I02. — Interstitial  endometritis.  A  typical  interstitial  endometritis 
with  scarcity  of  glands,  but  those  which  are  present  are  unusually  convoluted 
and  irregular.  The  interstitial  tissue  shows  marked  proliferation  and  some 
cellular  infiltration. 

i!,7io/o^y.  Hemorrhagic  endometritis  may  follow  an  attack  of 
acute  endometritis  or  itself  may  be  acute  in  the  sense  that  it 
develops  suddenly.  It  often  is  associated  with  and  probably 
is  produced  by  retroversion  and  retroflexion.  It  frequently 
follows  an  abortion  in  which  there  has  been  no  evidence  of  in- 
fection. It  is  associated  with  practically  all  myomata  of  the 
uterus  which  are  not  distinctly  intra-abdominal  and  peduncu- 
lated, and  is  found  in  many  cases  of  chronic  salpingitis. 


CHRONIC   ENDOMETRITIS 


223 


Pathology. — Two  distinct  types  are  noted  microscopically, 
but  both  may  be  present  in  an  individual  case.  Interstitial 
endometritis  shows  marked  increase  in  the  interglandular 
tissue  with  more  or  less  compression  of  the  glands.  This  in- 
creased tissue  is  almost  entirely  composed  of  small  round  cells 


x'^^fi 

•^■/   "'.,:'■■?■    ■  '  '''■■'  -.•  ^^^^-   ^.,f-f>..;'    :__;■■    »  •  ' 

Fig.  103. — Endometritis — glandular  hyperplasia.  So-called  glandular  endo- 
metritis. This  section  shows  a  somewhat  marked  glandular  hyperplasia  of  the 
endometrium,  the  glands  being  increased  both  in  number  and  size.  There  is  no 
change  in  the  stroma  here  and  no  leucocytic  infiltration. 


and  intracellular  substance,  and  when  of  long  standing  con- 
nective-tissue formation  is  observed. 

Glandular  endometritis  is  marked  by  great  hypertrophy  and 
even  hyperplasia  of  the  glands,  and  for  this  reason  is  sometimes 
termed  benign  adenoma.  The  glands  may  penetrate  the  mus- 
cular structure  for  a  short  distance  and  frequently  are  tortuous 
and  folded  upon  themselves.     Occasionally  one  may  see  more 


224  DISEASES    OF   THE   UTERINE  BODY 

than  a  single  layer  of  epithelium  lining  the  glands,  but  as  a  rule 
this  picture,  which  is  so  characteristic  of  malignant  disease,  is 
not  found  no  matter  how  marked  may  be  the  increase  in  size 
and  number  of  the  glands.  Small  cysts  may  form  in  long- 
standing cases  in  consequence  of  occlusion  of  the  gland  lumen. 

Symptoms. — The  principal  symptom,  as  the  name  indicates, 
is  hemorrhage  from  the  uterus,  usually  in  the  form  of  profuse, 
prolonged  menstruation.  The  periods  may  also  be  more  fre- 
quent than  normal  so  that  menstruation  is  longer  than  the  inter- 
menstrual interval.  Pain  is  generally  absent  and  there  may  or 
may  not  be  a  severe  leucorrheal  discharge  between  the  periods. 
It  is  surprising  in  how  many  instances  the  only  symptoms  are 
hemorrhage  and  secondary  anaemia. 

Physical  signs  may  be  entirely  wanting,  the  cervix  appearing 
perfectly  normal  and  the  uterus  unchanged  on  bi-manual  ex- 
amination, but  in  most  instances  the  uterus  is  larger  than  nor- 
mal, and  it  may  be  either  hard  or  soft  according  to  the  extent 
to  which  the  uterine  wall  has  undergone  connective-tissue 
infiltration. 

The  differential  diagnosis  is  of  great  importance  as  regards 
both  the  condition  of  the  endometrium  and  any  underlying 
cause  which  may  be  responsible  for  the  change  in  the  character 
of  the  mucosa,  since  treatment  directed  to  the- endometrium 
alone  is  likely  to  be  only  of  temporary  benefit  unless  such  cause 
is  removed.  It  should  be  remembered  that  the  characteristic 
symptom,  viz.,  hemorrhage,  may  be  due  to  extra-pelvic  condi- 
tions, such  as  anaemia  and  chronic  heart  lesions,  without  disease 
of  the  endometrium. 

Salpingitis,  ectopic  pregnancy,  and  uterine  myomata  can  be 
excluded  by  bi-manual  examination,  and  it  finally  should  be 
established  by  a  process  of  exclusion  that  there  is  no  cause  for 
hemorrhage  other  than  an  abnormal  condition  of  the  interior 
of  the  uterus.  Once  this  is  accomplished  the  possibility  of 
malignant  disease,  sclerosis  of  the  uterine  vessels,  and  polypi 
should  be  taken  into  consideration,  and  further  diagnosis  re- 


UTERINE  POLYPI  225 

served  until  examination  of  the  tissue  secured  by  curettage 
definitely  establishes  the  pathological  process  responsible  for 
the  hemorrhage. 

Polypi  are  seen  in  the  scrapings;  the  microscope  reveals 
either  a  normal  or  atrophic  endometrium  in  sclerosis;  while  the 
microscopic  appearance  of  the  endometrium  from  the  various 
types  of  endometritis  is  characteristic. 

Treatment. — The  last  step  in  diagnosis  is  curettage  and  it  is 
also  the  first  step  in  treatment.  Usually  nothing  more  than 
this  is  demanded  for  the  endometritis  itself,  and  so-called  "local 
treatment"  is  useless.  Indeed,  aside  from  diagnostic  curettage, 
hemorrhagic  endometritis  gives  the  only  clear-cut  gynaecologic 
indication  for  this  useful  but  much  abused  minor  operation. 

Displacements  must  be  overcome  and  myomata  or  diseased 
tubes  may  demand  removal.  While  the  diseased  endometrium 
becomes  of  secondary  importance  under  these  circumstances, 
it  nevertheless  needs  attention  unless  the  primary  disease  is  of 
such  a  character  that  the  uterus  is  removed  by  the  operation 
made  necessary  for  its  correction. 

The  endometrium  which  re-forms  after  curetting  is  usually 
healthy  but  occasionally  its  regeneration  is  accompanied  by  a 
return  of  the  bleeding.  Should  this  occur  the  curette  must  be 
used  again  and  microscopic  evidence  of  malignancy  be  sought 
in  all  the  fragments. 

Uterine  Polypi. — The  term  ^'polypus"  is  sometimes  used  to 
designate  sub-mucous  myomata  which  have  undergone  partial 
or  complete  expulsion  from  the  uterus,  but  this  use  of  the  word 
is  confusing. 

True  uterine  polypi  are  outgrowths  from  the  mucous  mem- 
brane. They  may  be  considered  as  a  locaKzed  endometritis, 
and  their  histological  structure  is  similar  to  that  of  uterine 
mucosa  which  is  the  subject  either  of  glandular  or  interstitial 
endometritis.  In  the  former  instance  they  have  been  given  the 
name  of  mucous  polypi,  in  the  latter  fibrous  polypi.  They 
never  attain  a  size  larger  than  a  cherry,  are  pedunculated,  and 
IS 


226  DISEASES    OF   THE   UTERINE  BODY 

as  they  bleed  freely  and  readily  escape  the  curette  they  are  the 
sources  of  some  very  mysterious  and  worrisome  hemorrhage. 
They  rarely  undergo  mahgnant  degeneration. 

When  one  is  discovered  it  should  be  removed  by  torsion  of 
its  pedicle  and  sharp  curettage  of  its  base. 

Sub -involution.^ — That  process  by  which  the  uterus  returns 
to  its  original  condition  after  abortion  or  labor  is  known  as  invo- 
lution, and  this  may  be  interfered  with  by  infection,  retention 
of  parts  of  the  ovum,  displacement  of  the  uterus,  or  failure 
upon  the  part  of  the  mother  to  nurse  her  child. 

The  symptoms  are  prolongation  of  the  lochial  discharge  and 
bearing  down  pain  in  the  pelvis. 

On  examination  the  uterus  is  found  to  be  large,  soft,  and 
boggy,  and  a  retroversion,  or  deeply  lacerated  or  patulous  cervix 
will  frequently  provide  an  immediate  clue  as  to  the  origin  of  the 
condition. 

Treatment. — Retained  fragments  of  membrane  or  placental 
tissue  should  be  removed  and  displacements  rectified,  after 
which  prolonged  hot  douches,  the  knee-chest  posture  once  or 
twice  daily,  and  the  administration  of  ergotin  and  hydrastis 
internally  results  in  prompt  relief. 

II  y  per  involution  of  the  uterus  after  labor  is  not  uncommon  and 
is  only  an  exaggeration  of  the  normal  process  by  which  the 
uterus  during  lactation  becomes  smaller  than  before  pregnancy 
occurred.  This  extreme  reduction  in  the  size  of  the  uterus  cor- 
rects itself  after  lactation  ceases.  Hyperinvolution,  therefore, 
is  of  no  importance  in  itself,  but  these  small  uteri  are  easily 
ruptured,  and  sounding  the  uterus  or  dilating  the  cervix  should 
under  no  circumstances  be  performed  if  hyperinvolution  has 
occurred. 

Chronic  Metritis. — Certain  authorities  (Pozzi)  insist  that 
inflammation  of  the  endometrium  presupposes  a  corresponding 
change  in  the  muscular  wall  of  the  uterus.  Whether  or  not 
this  is  true,  it  is  certain  that  in  many  instances  such  symptoms 
of  endometritis  as  leucorrhea  and  prolonged  or  profuse  men- 


UTERINE  FIBRO-MYOMATA  227 

struation,  are  followed  after  many  years  by  diminution  of  the 
menstrual  flow  and  the  gradual  development  of  menstrual  pain. 

Examination  of  patients  who  give  this  history  reveals  a 
rather  large  hard  uterus  which  is  uniform  in  shape  and  presents 
no  fibromatous  nodules,  and  it  is  reasonable  to  suppose  that  its 
muscular  wall  has  been  partially  substituted  by  connective 
tissue.  Occasionally  such  patients  complain  of  profuse  instead 
of  scanty  menstruation,  which  may  be  attributed  to  loss  of  con- 
tractile power  upon  the  part  of  the  uterine  muscles,  and  it  is 
probable  that  this  is  one  of  the  causes  of  some  otherwise  unex- 
plained hemorrhages  of  the  menopause. 

Treatment. — Treatment  in  most  instances  need  be  palliative 
only,  as  the  age  at  which  it  occurs  is  such  that  normal  cessation  of 
menstruation  may  be  expected  within  a  short  time.  Free 
purgation  and  hot  douches  with  occasional  scarification  of  the 
cervix  suffice  to  keep  the  patient  comfortable  until  menstrua- 
tion ceases  spontaneously. 

Uterine  Fibro-myomata. — Uterine  fibro-myomata,  ordinarily 
known  as  fibroids,  are  probably  the  most  common  tumors  of 
the  human  body.  It  is  said  (Hirst)  that  20  per  cent,  of  all 
women  have  fibroids. 

Etiology. — The  causative  factors  in  the  production  of  fibroid 
tumors  are  wholly  unknown.  They  make  their  appearance 
during  the  active  sexual  Hfe  of  the  patient,  are  rare  during 
its  early  years,  become  progressively  more  common  during  the 
third  and  fourth  decades,  and  sometimes  disappear  spon- 
taneously with  the  diminished  nutrition  of  the  uterus  at  and 
after  the  menopause.  Fibroids  are  relatively  more  common  in 
colored  women  and  in  sterile  women  of  both  races. 

Pathology. — Primarily  fibroids  are  composed  of  precisely  the 
same  histologic  structures  as  is  the  uterine  wall,  and  although 
connective  tissue  is  not  lacking  in  myomatous  tumors  nor  mus- 
cle in  fibromata,  the  preponderance  of  muscle  tissue  in  one 
tumor  and  of  connective  tissue  in  the  other  leads  to  their  differ- 
entiation as  myomata  and  fibromata  respectively. 


228 


DISEASES    OF   THE   UTERINE  BODY 


Fig.  104. — Interstitial  tibro-myoma  growing  in  fundus  and  surrounded  on  all 
sides  by  muscle  of  uterine  wall. 


UTERINE   FIBRO-MYOMATA 


229 


The  growths  may  vary  in  size  from  the  tiniest  '' seedlings" 
to  huge  tumors  which  almost  fill  the  abdominal  cavity.  They 
are  enclosed  in  a  dense  fibrous  capsule  into  which  the  nutritive 
vessels  penetrate. 

Their  starting  point  is  within  the  substance  of  the  uterine 
wall  (whether  from  the  vessel  walls  or  elsewhere  is  not  definitely 


Fig.  105. — Intra-abdominal — so-called  subperitoneal  fibro-myoma. 


determined)  and  they  may  remain  in  the  wall  of  the  uterus 
surrounded  on  all  sides  by  its  muscular  tissue;  they  may  grow 
toward  and  finally  into  the  uterine  cavity,  thus  being  covered 
externally  only  by  muscle;  or  outward  into  the  peritoneal 
cavity,  having  their  inner  boundary  only  made  up  of  the  uterine 
muscle. 


230 


DISEASES    OF   THE   UTERINE  BODY 


Fig.  io6. — Intra-uterine  or  submucous  fibro-myoma. 


Fig.  107. — Intramural  or  interstitial  fibro-myoma. 


UTERINE   riBRO-MYOMATA 


231 


According  to  the  final  location  of  the  tumor  it  is  given  a  dis- 
tinctive name. 

Those  remaining  in  the  uterine  wall  are  known  as  intra- 
mural or  interstitial,  those  in  the  uterine  cavity  as  sub-mucous 
or  intra-uterine,  and  those  projecting  largely  into  the  abdominal 


Fig.  108. — Intraligamentary    fibro-myoma,    which    also    is    properly    termed 

subserous. 

cavity  as  intra-abdominal  or  sub-peritoneal.  Owing  to  the 
latter  name  being  applied  also  to  such  tumors  as  grow  definitely 
under  the  parietal  peritoneum  or  between  the  folds  of  the  broad 
ligament,  those  which  project  distinctly  into  the  abdominal 
cavity  will,  for  the  sake  of  clearness,  be  termed  intra-abdominal 
instead  of  sub-serous  or  sub-peritoneal.     The  latter  terms  should 


232 


DISEASES    OF   THE   UTERINE  BODY 


be  used  to  define  those  growths  which  follow  the  floor  of  the 
pelvic  cavity  and  elevate  the  parietal  peritoneum  over  them. 

A  tumor  which  happens  to  be  so  situated  as  to  grow  from  the 
lateral  wall  of  the  uterus  at  such  a  point  as  to  force  itself  be- 
tween the  folds  of  the  broad  ligament  is  known  as  an  intra- 
ligamentary  fibroid. 


Fig.  log. — Leiomyofibroma  of  the  uterus.     This  microphotograph  shows  the 
whorls  of  non-striated  muscle  which  make  up  the  bulk  of  the  tumor. 


The  uterine  fibroid  may  be  sessile,  as  are  all  intramural 
growths,  or  pedunculated,  as  are  many  intra-uterine  and  some 
of  the  intra-abdominal. 

They  are  seldom  solitary  and  almost  invariably  are  found  in 
groups,  many  times  superimposed  one  upon  the  other. 

The  microscopic  picture  of  uncomplicated  fibro-myoma  is 
simple  and    reveals  whorls  of   muscle  fiber  interspersed  with 


UTERINE   FIBRO-MYOMATA 


233 


greater  or  less  amounts  of  connective  tissue,  the  whole  being 
arranged  concentrically.  Blood-vessels  and  lymphatics  are 
everywhere  present,  but  nerves  have  so  far  not  been  demon- 
strated. 

Various  forms  of  degeneration  are  met  with.     In  calcareous 


Fig.  1 10. — ^Leiomyosarcoma  of  the  uterus.  Sarcomatous  degeneration  of  a 
leiomyofibroma.  The  nuclear  elements  are  relatively  much  increased;  many  of 
them  are  atypical  in  size,  shape,  or  staining  power.  As  contrasted  with  the 
nonsarcomatous  leiomyofibroma  the  chief  difference  is  in  itsjgreater  cellularity. 
It  still  shows  the  whorls  of  cells  characteristic  of  the  leiomyofibroma  but  the 
nuclei  are  so  much  increased  that  the  neoplasm  is  definitely  malignant  and  capa- 
ble of  setting  up  metastases. 


degeneration  the  deposit  of  carbonate  and  phosphate  of  lime 
renders  the  growth  very  hard  and  produces  the  so-called  "stone 
tumor."  Myxomatous  degeneration  is  recognized  by  some 
authorities  while  others  contend  that  such  processes  are  really 
sarcomatous. 


234  DISEASES    OF   THE   UTERINE  BODY 

Sarcomata  may  originate  in  the  growth,  and  carcinomata  in 
the  endometrium  covering  its  intra-uterine  surface.  Necrotic 
processes  are  fairly  common  and  are  the  result  either  of  infec- 
tion or  of  mechanical  interference  with  the  circulation. 

Hyperplastic  endometritis  is  an  invariable  accompaniment 
of  intra-uterine  myomata,  is  frequently  present  in  intramural 
growths,  and  occasionally  is  associated  with  intra-abdominal 
tumors. 

Symptoms  and  Physical  Signs. — The  only  symptoms  due 
directly  to  an  uncomplicated  fibroid  are  those  produced  by  the 
size  and  location  of  the  growth.  An  intra-abdominal  fibroid 
of  moderate  size  may  exist  without  symptoms  and  be  dis- 
covered only  by  accident.  Large  intra-abdominal  growths  are 
productive  of  symptoms  from  pressure  upon  the  viscera.  In 
this  way  irritability  of  the  bladder,  obstinate  constipation,  and 
hydronephrosis  may  be  caused  respectively  by  pressure  on  the 
bladder,  pressure  on  the  rectum,  or  pinching  of  the  ureter  be- 
tween the  tumor  and  the  wall  of  the  bony  pelvis. 

Intra-uterine  tumors,  by  acting  as  foreign  bodies,  may  stimu- 
late expulsive  efforts  on  the  part  of  the  uterus  and  thus  cause 
labor-like  pains. 

Sub-peritoneal  tumors  grow  principally  in  the  pelvic  cavity 
and  are  productive  of  earlier  pressure  symptoms  than  the  other 
varieties  on  account  of  their  proximity  to  the  fixed  bony  walls. 

Hemorrhage,  either  menorrhagic  or  metrorrhagic  in  type, 
is  a  common  result  of  intra-uterine  and  intramural  tumors,  and 
is  brought  about  by  the  hyperplastic  endometritis  which  always 
accompanies  the  former  and  usually  the  latter,  together  with 
the  increased  size  of  the  uterus  which  adds  greatly  to  the  area 
of  the  endometrium.  These  hemorrhages  may  amount  to 
but  little  more  than  a  trivial  increase  in  the  duration  or  quantity 
of  the  menstrual  flow,  or  they  may  be  so  severe  as  actually  to 
jeopardize  life.  In  the  average  case  they  are  serious  enough  to 
produce  a  moderate  grade  of  anaemia,  as  the  patient  hardly 
recovers   from  one  menstrual  flow  before  the  succeeding  one 


DIAGNOSIS   OF   UTERINE   EIBRO-MYOMATA  235 

begins.  Shortness  of  breath,  palpitation  of  the  heart,  and 
languor  are  then  present  in  proportion  to  the  degree  of  anaemia 
which  exists.  A  moderate  serous  leucorrhea  may  occur  either 
before  or  after  each  menstrual  period. 

SteriHty  is  the  rule  in  patients  having  intra-uterine  or  inter- 
stitial fibroids.  Pregnancy  however  may  occur,  in  which 
event  the  tumor  grows  more  rapidly  than  before,  and  should  the 
pregnancy  continue  until  term  and  the  patient  be  delivered 
without  serious  accident,  involution  of  the  tumor,  but  not  its 
disappearance  can  be  expected. 

Physical  Signs. — Tumors  arising  above  the  pelvic  inlet  pro- 
duce abdominal  enlargement  in  proportion  to  their  size.  On 
palpation  they  are  generally  firm,  nodular,  and  irregular  in 
outline,  although  in  the  presence  of  oedema  or  immediately 
preceding  menstruation  more  or  less  elasticity  is  evident.  Oc- 
casionally but  a  single  fibroid  is  present  and  this  may  be  smooth 
and  regular  in  outline. 

The  tumor  may  be  situated  at  either  side  of  or  in  the  median 
line,  and  its  lower  border  cannot  be  defined  by  abdominal  pal- 
pation because  of  its  pelvic  origin.  Flatness  on  percussion  is 
always  present  if  the  growth  is  sufiiciently  large  to  come  into 
contact  with  the  anterior  abdominal  wall.  On  auscultation  a 
bruit  synchronous  with  the  radial  pulse  may  very  rarely  be 
heard. 

Inspection  of  the  vulva  usually  reveals  no  discoloration  even 
with  an  impacted  tumor. 

On  digital  examination  the  cervix  is  hard  and  the  tumor  is 
found  to  be  directly  connected  with  it.  Above  the  cervix  the 
outHnes  of  the  growth  are  perceptible  and  nodules  are  generally 
palpable.  On  bi-manual  examination,  motion  conveyed  to  the 
tumor  by  one  hand  is  transmitted  directly  to  that  portion  of 
the  tumor  palpated  by  the  other.  The  sound,  when  used, 
shows  the  uterine  cavity  to  be  greatly  elongated  and  often 
irregular  in  shape. 

Differential    Diagnosis. — In    the    differential    diagnosis    of 


236  DISEASES    OF   THE   UTERINE  BODY 

uterine  fibroids  the  fact  to  be  ascertained  is  whether  the  bleed- 
ing, abdominal  enlargement,  and  pressure  symptoms  because 
of  which  the  patient  presents  herself,  are  due  to  a  new  growth, 
and  if  so  whether  the  growth  is  a  uterine  fibroid. 

Pregnancy,  either  normal  or  abnormal,  is  at  one  time  or 
another  the  most  serious  stumbling  block.  Typical  pregnancy 
causes  cessation  of  menstruation;  typically,  fibroids  increase 
the  frequency  and  amount  of  blood  lost,  but  in  pregnancy  men- 
struation may  continue  for  the  first  three  or  four  months  until 
the  deciduae  permanently  fuse;  central  placenta  previa  may 
produce  intermittent  hemorrhage  until  pregnancy  terminates; 
normal  pregnancy  with  threatened  abortion  produces  irregular 
hemorrhage;  ectopic  pregnancy  rarely  fails  to  have  irregular 
bleeding  as  one  of  its  symptoms;  and  the  various  types  of  mole 
and  deciduomamalignum,  which  may  be  considered  as  sequelae 
of  pregnancy,  all  cause  some  bleeding  and  are  associated  with 
enlargement  of  the  uterus. 

On  the  other  hand,  a  fibroid  which  is  distinctly  intra-abdom- 
inal may  not  disturb  the  menstrual  functions  at  any  time,  and 
after  the  menopause  may  grow  rapidly  without  producing 
hemorrhage.  Therefore,  symptom  hemorrhage,  alone,  must 
not  be  considered  as  diagnostic  of  a  fibroid  tumor,  and  this 
subjective  symptom  needs  the  confirmatory  evidence  of  the 
physical  signs  characteristic  of  a  fibroid  before  the  diagnosis 
can  be  considered  as  established. 

Abdominal  enlargement  in  women  is  most  frequently  caused 
by  pregnancy,  by  fibroids,  by  ovarian  tumors,  and  ascites,  in 
the  order  named,  but  tuberculous  peritonitis,  carcinoma  of  the 
abdominal  viscera,  rapid  deposit  of  fat  in  the  abdominal 
wall,  and  the'  hysterical  phantom  tumor  need  always  to  be 
considered. 

In  reverse  order,  the  phantom  tumor  is  tympanitic  on  per- 
cussion and  disappears  under  anaesthesia;  a  fat  abdominal  wall 
may  be  picked  up  bodily;  carcinoma,  while  nodular,  is  palpable 
over  various  and  widely  separated  portions  of  the  abdomen; 


DIFFERENTIAL  DIAGNOSIS  OF  UTERINE  FIBRO-MYOMATA      237 

and  tuberculous  peritonitis  presents  some  elevation  of  tempera- 
ture, some  pain,  isolated  areas  of  dullness,  a  quick  pulse  and 
loss  of  weight. 

Ascites  produces  uniform  enlargement.  Ascitic  fluid  sinks 
to  the  lowest  portion  of  the  abdomen  and  thus  the  dullness  shifts 
as  the  patient  is  turned  from  side  to  side,  sits  up,  or  lies  down. 

Further,  none  of  these  conditions  excepting  carcinoma  and 
tuberculous  peritonitis  develop  in,  and  extend  upward  out  of, 
the  pelvic  cavity. 

It  is  usually  stated  that  ovarian  tumors  are  elastic,  fibroids 
hard;  that  ovarian  tumors  spring  from  one  side  rather  than  the 
mid-line  and  are  regular  in  outline,  while  fibroids  are  irregular 
or  nodular.  While  the  foregoing  is  true  in  most  instances, 
some  ovarian  tumors  nevertheless  are  hard,  and  oedematous 
fibroids  are  elastic;  rapidly  growing  multilocular  ovarian  cysts 
may  be  irregular,  and  large  intra-uterine  fibroids  are  regularly 
globular  in  shape  while  some  fibroids  are  pedunculated  and 
lateral,  so  that  unless  the  uterus  can  he  distinctly  outlined  as  an 
organ  separate  from  the  growth,  the  differential  diagnosis  be- 
tween an  ovarian  tumor  and  a  uterine  fibroid  may  be  impossible. 

The  abdominal  enlargement  of  pregnancy  is  of  rapid  growth, 
and  if  amenorrhea  is  present  the  uterus  should  correspond  in 
size  to  its  duration.  Fibroids  are  of  slow  growth.  The  preg- 
nant uterus  contracts  under  the  hand  while  such  contraction 
takes  place  with  fibroids  only  if  the  growth  is  intra-uterine.  A 
uterine  bruit  may  be  present  in  both  conditions  but  far  more 
frequently  in  pregnancy.  If  the  tumor  is  larger  than  a  four 
months'  pregnancy  the  foetus  can  be  detected  in  some  fashion 
if  the  patient  is  pregnant,  either  by  foetal  heart  sounds,  foetal 
motion,  or  palpation  of  foetal  parts.  The  cervix  is  softened  in 
pregnancy,  hard  in  fibroids;  and  finally  time  can  be  depended 
on  to  complete  the  differential  diagnosis  if  the  symptoms  are 
not  so  urgent  as  to  demand  early  interference. 

The  student  always  has  to  bear  in  mind  the  tremendous 
probability  of  pregnancy  during  the  child-bearing  age,  and  the 


238  DISEASES    OF   THE   UTERINE  BODY 

relative  infrequency  of  fibroids,  and  further  that  fibroids  and 
pregnancy  may  co-exist. 

Prognosis. — The  prognosis  of  untreated  fibro-myomata  is  to 
a  great  extent  dependent  upon  the  presence  or  possibiUty  of 
compHcations  rather  than  the  existence  of  a  tumor. 

Very  large  tumors  jeopardize  life.  Intra-uterine  tumors 
readily  become  infected  and  undergo  necrosis.  Hemorrhage 
by  itself  is  rarely  fatal,  but  profound  anaemia  exercises  a  dele- 
terious effect  upon  the  heart  and  renders  the  patient  a  fit  sub- 
ject for  intercurrent  disease.  Inflammatory  disease  of  the 
tubes  is  a  frequent  concomitant,  and  sarcomatous  degeneration 
is  found  entirely  too  often  to  be  a  coincidence  as  also  is  malig- 
nant disease  of  the  cervix. 

The  occurrence  of  pregnancy  is  distinctly  a  serious  matter, 
and  labor  may  be  interfered  with  by  the  presence  of  a  fibroid 
in  the  lower  uterine  segment.  Abortion  is  more  likely  to  occur 
than  it  is  with  a  normal  uterus,  and  both  abortion  and' full-term 
labor  are  more  likely  to  be  followed  by  infection.  Bruising  of  a 
tumor  in  the  lower  uterine  segment  may  cause  necrosis  and  so 
lower  its  resistance  to  infection,  and  abnormal  implantation 
or  retention  of  the  placenta  lead  to  obstetric  complications. 

Altogether  one  might  say  that  the  prognosis  in  an  individual 
case  may  be  very  good,  while  in  a  large  series  of  cases  enough 
complications  are  certain  to  be  found  to  jeopardize  an  occasional 
life,  and  render  many  others  hardly  worth  living. 

The  menopause  may  put  a  stop  to  some  of  the  annoyances 
but  cannot  be  depended  upon  to  end  all  the  complications. 

Treatment. — There  is  no  medical  treatment  for  the  tumor 
itself.  Ergot  and  hydrastis  assist  in  controlling  the  hemorrhage, 
and  ergot  may  cause  the  eventual  expulsion  of  an  intra-uterine 
tumor,  but  only  after  much  pain,  hemorrhage,  and  danger  from 
necrosis  and  infection.  Rest  in  bed  during  the  hemorrhage 
will  diminish  the  amount  of  blood  lost,  and  large  doses  of  iron 
between  the  periods  help  to  overcome  anaemia.  Strychnine, 
digitalis,   good   food   and   fresh   air,    all   assist  in  remedying 


TREATMENT   OF   UTERINE  FIBRO-MYOMATA  239 

the  results  of  the  bleeding,  but  they  have  no  effect  on  the 
tumor. 

Galvanic  electricity  with  the  positive  pole  in  the  uterus 
diminishes  the  bleeding,  but  every  individual  treatment  is 
fraught  with  the  risk  of  infection,  while  the  necessary  repetition 
of  the  treatment  makes  the  method  on  the  whole  more  danger- 
ous than  operation,  and  it  fails  to  rid  the  patient  of  her  tumor. 

Curettage,  to  temporarily  check  the  hemorrhage,  is  sometimes 
judicious  when  the  bleeding  comes  from  a  hyperplastic  endome- 
trium and  not  from  the  surface  of  an  intra-uterine  growth. 

Recently  the  use  of  the  X-ray  and  radium  have  come  into  vogue 
in  some  quarters  for  the  cure  of  uterine  fibroids.  That  these 
tumors  often  diminish  in  size  under  the  use  of  massive  dosage 
with  special  appliances  is  quite  certain — that  they  are  entirely 
destroyed  is  improbable — and  it  remains  to  be  seen  whether  a 
tumor  which  has  been  shrunken  by  the  X-ray  treatment  loses 
its  predilection  for  sarcomatous  degeneration,  or  whether  a 
uterus  which  contains  a  fibroid  does  not  continue  to  menace  life 
by  possible  carcinomatous  changes  in  the  endometrium. 
With  our  present  knowledge  radio-therapy  should  be  reserved 
for  the  treatment  of  patients  who  refuse  operation  or  in  whom 
operation  is  for  any  reason  injudicious  or  extra-hazardous. 

Surgical  Treatment. — The  indications  for  the  surgical  removal 
of  fibroid  tumors  are  based  upon  the  ordinary  rules  of  surgery. 
When  the  disease  is  more  dangerous  than  the  operation  required 
for  its  removal,  operation  should  be  advised.  When  the  risk  of 
operation  is  to  be  preferred  to  the  discomfort  engendered  by  the 
disease,  operation  should  be  advised.  Based  upon  these  con- 
siderations, only  a  very  small  symptomless  fibroid  which  has 
been  discovered  in  the  course  of  the  routine  examination  of  a 
middle-aged  woman,  should  be  ignored. 

All  intra-uterine  growths  should  be  removed  as  should  tumors 
which  are  productive  of  pressure  symptoms  either  from  their 
size  or  location.  All  fibroids  which  cause  free  bleeding,  grow 
rapidly,  or  are  painful,  should  be  subjected  to  radical  operation. 


240  DISEASES   OF   THE  UTERINE  BODY 

The  term  ''large  growths"  is  a  relative  one,  and  a  small  tumor  in 
a  young  woman  is  a  greater  menace  to  life  and  health  than  a 
much  larger  one  at  or  near  the  menopause,  because  of  the  greater 
probability  of  some  positive  need  for  operation  arising  in  the 
former  than  in  the  latter,  and  also  because  it  has  a  longer 
period  of  time  in  which  to  grow. 

Some  few  tumors  may  be  watched  carefully  to  ascertain 
whether  or  not  they  are  growing,  but  in  a  general  way  all  symp- 
tom-producing fibroids  should  be  removed.  The  mortality  rate 
from  hysterectomy  actually  is  smaller  than  that  from  malignant 
degeneration  of  fibroids  or  the  incidence  of  malignancy  in  the 
uterus  which  contains  them.  They  ought  therefore  to  be  re- 
moved even  if  possible  malignancy  were  the  only  indication, 
instead  of  which  it  is  but  one  of  many  indications. 

In  a  recent  series  of  the  author's,  out  of  100  patients  upon 
whom  hysterectomy  was  proposed  for  the  removal  of  fib- 
roids, one  proved  to  be  inoperable  because  of  gross  sarco- 
matous degeneration,  another  was  sarcomatous  on  microscopic 
examination  and  recurred,  and  two  uteri  contained  carcinomata 
which  recurred  after  operation.  A  high  grade  of  anaemia,  gross 
heart  lesions  with  decompensation,  and  advanced  nephritis,  here 
as  elsewhere  are  distinct  contra-indications  to  the  performance 
of  a  radical  operation. 

Choice  of  Methods. — Myomectomy,  vaginal  or  abdominal, 
and  hysterectomy,  vaginal  or  abdominal,  are  the  methods  at  our 
command  for  the  removal  of  fibroid  tumors  of  the  uterus. 

The  vaginal  removal  of  small,  single,  pedunculated,  intra- 
uterine myomata  meets  with  the  approval  of  all.  Large  tumors 
situated  within  the  uterus  may  also  be  removed  in  the  same 
manner,  but  the  risks  are  as  great  as  from  abdominal  section 
and  hysterectomy,  and  when  one  considers  the  possibility  of 
more  than  one  tumor  being  present  the  latter  method  is 
preferable. 

Vaginal  hysterectomy  may  be  performed  for  tumors  up  to  the 
size  of  a  small  foetal  head,  but  the  vagina  must  be  capacious  and 


MALIGNANT  DISEASE   OF  THE  UTERINE  BODY  24 1 

the  ligaments  so  relaxed  that  the  uterus  can  be  well  drawn  down 
if  the  operation  is  to  be  as  safe  as  abdominal  hysterectomy,  and 
salpingitis  or  other  adhesion-producing  complications  should  be 
absent. 

Abdominal  myomectomy  is  especially  applicable  to  peduncu- 
lated intra-abdominal  growths,  and  should  be  used  for  sessile 
growths  only  if  their  number  is  small  and  the  patient  so  young 
that  child-bearing  ought  not  to  be  interfered  with. 

Supra-vaginal  hysterectomy  is  applicable  to  the  great  majority 
of  fibroids  which  need  removal.  It  allows  one  to  deal  with  com- 
plications most  satisfactorily,  has  a  very  low  mortality  rate, 
and  does  not  necessitate  removal  of  the  ovaries.  Panhysterec- 
tomy should  be  done  if  the  tumor,  uterine  body,  or  cervix  gives 
ground  for  any  suspicion  of  malignancy. 

The  choice  of  methods  will  also  depend  somewhat  upon  the 
operator's  training.  A  skilled  vaginal  surgeon  can  overcome 
difficulties  through  the  lower  route  which  would  prove  insur- 
mountable for  the  average  operator. 

The  great  advantage  of  the  vaginal  route  lies  in  the  absence 
of  operative  shock.  Nature  having  accustomed  the  lower  pelvis 
and  va-gina  to  withstand  trauma  through  the  world  old  process 
of  child  bearing,  but  the  disadvantages  of  this  route,  in  any  but 
the  simplest  cases,  are  tremendous  for  the  average  operator. 

MALIGNANT  DISEASE  OF  THE  UTERINE  BODY 

Three  forms  of  malignant  disease  are  found  in  the  body  of  the 
uterus:  carcinoma,  sarcoma,  and  deciduoma  malignum.  They 
are  not  grouped  together  because  of  any  relationship,  but  be- 
cause their  comparatively  infrequent  occurrence,  aside  from  the 
presence  of  the  first  two  as  complicating  factors  in  pre-existing 
fibroids,  does  not  justify  the  devotion  of  a  separate  section  to 
each  of  them. 

Cancer  of  the  uterine  body  is  much  less  frequently  found  than 
cancer  of  the  cervix,  and  unlike  the  latter  is  as  common  in  nulli- 
16 


242 


DISEASES   OF   THE   UTERINE  BODY 


parae  as  in  multiparae.     It  grows  more  slowly  than  cervical 
carcinoma  and  metastases  are  relatively  late  in  occurring. 

The  usual  symptoms  are  irregular  bleeding  at  or  after  the 
menopause,  alternating  with  a  foul-smelling  watery  or  bloody 
discharge.     On  bi-manual  examination  no  change  can  be  made 


Fig.  III. — Adenocciiciiioma  originating  in  the  endometrium.  Here  deeply 
infiltrating  the  uterine  wall.  The  section  shows  a  ground  work  of  uterine  muscle 
which  is  seen  at  the  lower  left  corner  of  the  field  and  which  is  somewhat  infiltrated 
with  leucocytes.  The  remaining  portions  of  the  plate  are  filled  with  very  atypical 
gland-like  spaces  having  an  epithelium  unlike  that  normally  found  in  the  uterus 
made  up  of  very  tall  columnar  cells  showing  some  tendency  to  stratification. 
These  atypical  gland-like  spaces  are  infiltrating  the  muscle. 


out  early  in  the  disease,  but  as  it  progresses  the  uterus  becomes 
larger,  and  eventually  the  entire  pelvis  may  be  choked  by  masses 
of  cancerous  tissue.  The  diagnosis  is  never  positive  in  the  early 
stages  excepting  upon  the  microscopic  examination  of  specimens 
removed  by  exploratory  curettage,  and  irregular  bleeding  at  or 


MALIGNANT  DISEASE   OF   THE   UTERINE  BODY 


243 


beyond  the  menopause  is  by  all  means  the  most  frequent  indi- 
cation for  curettage  for  diagnostic  purposes. 

The  treatment  of  carcinoma  of  the  body  of  the  uterus  is 
panhysterectomy  in  all  cases  which  are  diagnosed  before  metas- 
tases or  extension  to  surrounding  organs  has  taken  place,  and 


Fig.  112. — Syncytioma  Malignum.  Chorio-epithelioma.  In  this  section 
the  uninvaded  uterine  muscle  is  seen  at  the  upper  right.  Between  this  and  the 
mass  of  blood  clot  in  the  lower  left  there  are  irregular  masses  of  characteristic 
cells  of  this  tumor.  The  syncytial  cells  have  irregular  darkly  staining  nuclear 
masses  and  are  not  as  numerous  as  are  the  derivatives  of  the  Langhan's  layer. 
The  latter  can  be  differentiated  by  their  regular  shape  and  definite  cell  outlines. 


the  prognosis  as  to  recurrence  is  materially  better  than  after 
radical  operation  for  cancer  of  the  cervix. 

When  metastases  or  regional  extension  has  taken  place  no 
operation  is  of  the  slightest  avail,  and  radiotherapy  with  massive 
dosage  should  be  tried  as  a  last  resort. 

Primary  sarcoma  of  the  uterus  is  a  rare  disease,  but  as  a 


244  DISEASES   OE   THE   UTERINE  BODY 

secondary  affection  it  may  occur  in  patients  who  have  fibroids, 
and  also  by  metastasis  from  sarcoma  in  other  portions  of  the 
body.  Its  symptoms  are  the  same  as  those  of  carcinoma,  and 
previous  to  operation  it  can  be  differentiated  from  it  by  micro- 
scopic examination  only.  The  treatment  also  is  the  same,  radi- 
cal removal  if  the  disease  is  confined  to  the  uterus,  radium  and 
X-ray  therapy  if  extension  or  metastases  render  the  condition 
hopeless  from  an  operative  standpoint. 

In  one  instance  under  the  author's  care  which  both  macro- 
scopically  and  microscopically  was  sarcomatous,  Coley's  toxins 
seemed  to  cause  a  diminution  in  the  size  of  the  growth  with  entire 
abatement  of  the  symptoms. 

Deciduoma  malignum,  more  correctly  chorio-epithelioma,  is 
due  to  the  taking  on  of  malignant  characteristics  by  the  large 
flat  epithelial  cells  which  normally  cover  the  chorionic  villi. 
It  therefore  occurs  only  after  the  termination  of  pregnancy  by 
abortion,  full  term  labor,  or  the  evacuation  of  a  mole.  A 
hydatidif orm  mole  is  the  most  frequent  immediate  antecedent  of 
this  form  of  malignant  disease,  which  reveals  itself  by  the 
appearance  of  hemorrhage  and  rapid  growth  of  the  uterus  at  a 
stage  when  it  should  be  subsiding  in  size.  Diagnosis  is  readily 
made  microscopically,  and  treatment  is  by  extirpation  of  the 
uterus  if  the  patient  is  seen  sufficiently  early.  In  some  re- 
spects, however,  this  is  the  most  malignant  type  of  malignant 
disease,  showing  rapid  growth  and  early  metastases,  especially 
to  the  bones,  and  operation  must  be  done  at  the  earliest  possible 
moment  if  it  is  to  be  of  any  avail. 

One  cannot  close  a  section  upon  diseases  of  the  uterus  without 
remarking  that  malignant  disease  is  the  opprobrium  of  surgery, 
that  malignant  disease  of  the  uterus  is  the  especial  opprobrium 
of  the  specialist  in  abdominal  and  pelvic  surgery,  and  that  in 
spite  of  the  wide  dissemination  of  knowledge  concerning  can- 
cer, neither  the  laity  nor  general  practitioners  of  medicine  are 
sufficiently  alert  to  the  early  symptoms  of  malignancy  and 
the  absolute  necessity  for  its  early  diagnosis. 


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LYNCH. — Fibroid  Tumors  Complicating  Pregnancy  and  Labor.     Am.  J.  Obst., 

1913,  Ixviii,  427. 
MACKENRODT. — Zur  Frage  der  konservativen  Myomebehandlung.     Zeitsch. 

f.  Geb.  und  Gyn.,  191 2,  Ixxii,  186. 
SCHAUTA. — Ueber    moderne    Myombehandlung.     Wien.    med.    Woch.,    1913, 

Ixiii,  13. 
HALL. — Some  of  the  Reasons  for  Advising  Early  Operation  for  Fibroid  Tumors 

of  the  Uterus.     Am.  J.  Obst.,  1913,  Ixvii,  96. 
KELLY! — The  Radium  Treatment  of  Fibroid  Tumors.     Surg.,  Gyn.  &"  Obst., 

1915,  XX,  271. 

ALBERS-SCHOENBERG.— Ergebnisse    der    Roentgentherapie    der    Myome. 

Forlschr.  a.  d.  Geb.  d.  Roentgenstrahlen,  191 2,  xix,  324. 
MILLER. — The  Relation  between  Sarcoma  and  Myoma  of  the  Uterus  and  Its 

Bearing  on  X-ray  Therapy  of  Uterine  Myomata.     Surg.,  Gyn.  6°  Obst., 

1913,  xvi,  315. 

BORDIER. — The    Radiotherapeutic    Treatment    of    Uterine    Fibroma.    Proc. 

Roy.  Soc.  Med.,  1911-12,  v.;  Elcdroiherap.  Sec,  125;  Arch-Rocntgen  Ray, 

1912-13,  xvii,  130. 
SIPPEL. — Die  Bchandlung  der  Uterusmyome  mit  Roentgenstrahlen.     Miinch, 

med.  Woch.,  1913,  Ix,  2226. 
BALDY. — The  Mortality  in  Operations  upon  Fibroid  Tumors  of  the  Uterus. 

Am.  J.  Obst.,  1905,  Hi,  370;  Jr.  Am.  Gyn.  Soc,  1905,  xxx,  450. 
JANSEN. — Myom  und  Corpuskarzinom  am  Uterus.     Monats  /.  Geb.  und  Gyn., 

1914,  xxxix,  207. 

ILL. — Cancer  of  the  Uterus  and  Fibroid  Tumors  from  a  Clinical  Standpoint. 

Am.  J.  Obst.,  1913,  Ixviii,  922. 
CULLEN. — Operations  on  Patients  with  a  Haemoglobin  of  Forty  Per  cent,  or 

Less.     Trans.  Am.  Gyn.  Soc,  1913,  xxxviii,  248. 
BYFORD. — The  Significance  of  Anaemia  as  an  Operative  Risk.     Trans.  Am. 

Gyn.  Soc,  1913,  xxxviii,  237. 


REFERENCES  247 

WILSON. — The  Operative  Risk  of  Fibroids,  Complicated  by  Anaemia.     Austra. 

m.  Gaz.,  1914,  XXXV,  574. 
SKEEL,  R.  E. — The  Radical  Treatment  of  Uterine  Fibroids  Based  on  Their 

Association  with  Malignancy.     Clevel.  M.  /.,  19137  xii,  166. 
WEST. — When  Shall  We  Perform  Myomectomy  and  when   Hysterectomy   in 

Uterine  Fibromyomata.     Am.  J.  Obst.,  1907,  Ivi,  700. 
THORN. — Zur  vaginalen  Myomotomie.     Monats.  f.  Geh.  und  Gyn.,  1909,  xxx, 

570. 
BANDLER.— Vaginal  Surgery.     N.  York  M.  J.,  19 13,  xcvii,  797. 
WEIBEL.— Die  Klinische  Stellung  des   Carcinoma  Corporis  Uteri.     Arch.  /. 

Gyn.,  1913,  c,  135. 
ATLEE.— Uterine  Cancer  and  Its  Early  Diagnosis.     Med.  Rec,  191 1,  Ixxix,  897. 
EDEN.— The  Clinical  Diagnosis  of  Malignant  Disease  of  the  Body  of  the  Uterus. 

Lancet,  1912,  i,  1392. 
OFFERGELD. — Ueber  die  Histologie  der  Adenocarcinome  im  Uterusfundus. 

Arch.  f.  Gyn.,  1906,  Ixxviii,  289. 

Maunee  af  Heurltn  Zur  Kenntnis  des  Baues,  des  Wachstums  und  der 

histologischen  Diagnose  des   Carcinoma  Corporis  uteri  u.  s.  w.     Arch.  f. 

Gyn.,  191 1,  xciv,  402. 
HEIMANN,  F.— Wietere  Beitrage  zur  Klinik  und  Histologie  des  Chorioepithe- 

lioms.     Zeitsch.  f.  Geh.  und  Gyn.,  1913,  Ixxiv,  600. 
STRASSER.— The   Clinical  and  Pathological  Features  of    Chorioepithelioma 

Malignum.     Afn.  J.  ObsL,  1915,  Ixxi,  441. 
PESTALOSSA.— ChorioepitheHoma.     Atti  delta  Societa  Italiana,   ObsL   Gyn., 

1913,  xviii;  Review  Am.  J.  Obst.,  Ixxi,  1915,  161. 


CHAPTER  IX 
DISPLACEMENTS  OF  THE  UTERUS 

Normally  the  uterus  is  situated  nearly  in  the  mid-line  of  the 
body,  deviating  a  trifle  to  the  right  or  left  when  the  bladder  is 
full.  The  fundus  rests  upon  the  bladder,  and  when  that  viscus 
is  empty  the  fundus  and  posterior  wall  of  the  body  may  be 
palpated  immediately  behind  the  symphysis  pubis  on  bi-manual 
examination.  The  long  axis  of  the  uterus  meets  the  vagina  very 
nearly  at  a  right  angle,  while  the  cervix  lies  posterior  to  but  in 
a  line  approximately  paralleling  the  pelvic  axis,  the  junction  of 
the  body  and  cervix  being  about  3  cm.  in  front  of  the  sacrum. 
The  normal  position  of  the  uterus  therefore  is  one  of  anteversion 
and  moderate  anteflexion.  The  forces  which  maintain  the 
uterus  in  this  location  and  position  are  its  attachments  to  sur- 
rounding structures  acting  with  the  assistance  of  intra-abdom- 
inal pressure.  The  sacro-uterine  ligaments  maintain  the  junc- 
tion of  the  body  and  cervix  at  a  given  level  by  their  tonicity, 
and  are  assisted  by  a  collar  of  connective  tissue  which  entirely 
surrounds  the  supra-vaginal  portion  of  the  cervix.  This  para- 
metritic tissue  extends  laterally  between  the  folds  of  the  broad 
ligaments  to  the  pelvic  wall  on  either  side.  Anteriorly  the 
vesico-vaginal  septum  takes  a  portion  of  the  weight  of  the  uterus, 
and  in  addition  the  cervix  rests  upon  the  posterior  vaginal  wall 
when  that  canal  is  not  distended.  As  the  location  of  the  uterus 
as  a  whole  is  maintained  by  the  foregoing  factors,  so  its  position 
or  attitude  is  determined  by  the  points  to  which  the  surrounding 
structures  are  attached  and  the  direction  in  which  intra-abdom- 
inal pressure  tends  to  drive  it.  Even  the  location  is  somewhat 
dependent  upon  its  position,  as  for  example,  it  is  impossible 

248 


FORCES  MAINTAINING  UTERUS  IN  NORMAL  POSITION       249 

for  the  uterus  to  descend  through  the  vaginal  canal  so  long  as 
it  remains  at  a  right  angle  to  it,  and  it  must  assume  such  a 
position  that  its  long  axis  points  in  the  same  general  direction 
as  the  long  axis  of  the  vagina. 

It  has  been  pointed  out  that  the  vicinity  of  the  internal  uter- 
ine orifice  is  the  most  nearly  fixed  of  any  portion  of  the  uterus, 
and  it  is  about  this  point  that  the  uterus  deviates  in  mal- 
positions. 

The  round  ligaments  serve  as  slender  guy  ropes  to  draw  the 
fundus  forward,  rotating  the  uterus  about  a  transverse  line 
drawn  through  its  internal  orifice,  and  they  are  not  opposed 
in  their  action  by  any  similar  structures  attached  posteriorly. 
The  mechanical  effect  of  intra-abdominal  pressure  resembles 
very  closely  the  conditions  which  would  be  present  if  the  ab- 
dominal cavity  were  filled  with  water.  The  uterus  being  of 
low  specific  gravity,  its  fundus  and  body  above  the  line  of 
peritoneal  attachment  are  readily  displaced,  and  for  the  same 
reason  they  are  also  readily  replaced  by  such  trifling  force  as  the 
round  ligaments  are  able  to  exert.  So  long  as  the  fundus  re- 
mains tilted  forward,  the  hydrostatic  pressure  of  the  abdoniinal 
contents  is  exerted  on  its  posterior  face  and  assists  in  keeping  it 
forward.  When  the  fundus  is  displaced  backward  to  a  suffi- 
cient extent  to  bring  this  pressure  to  bear  on  its  anterior  surface, 
the  natural  mechanical  tendency  is  to  keep  it  back,  but  in  a 
condition  of  health  the  round  ligaments  more  than  counter- 
balance this  and  again  draw  the  fundus  into  its  normal 
position. 

Primarily,  then,  the  uterus  is  not  a  fixed  organ  but  possesses 
a  wide  range  of  mobility;  neither  is  it  rigid,  for  it  possesses  a 
moderate  degree  of  flexibility.  It  may  be  displaced  or  bent 
upon  itself  but  under  normal  conditions  tends  to  return  to  a 
fairly  definite  location  and  position  in  the  pelvis  as  soon  as  the 
displacing  force  ceases  to  act,  and  only  when  it  fails  to  return  to 
this  location  and  position  can  pathological  displacement  be  said 
to  exist. 


250 


DISPLACEMENTS    OF   THE    UTERUS 


CLASSIFICATION    OF   DISPLACEMENTS 

Departures  of  the  uterus  from  its  ordinary  situation  are 
defined  either  as  mal-locations  or  mal-positions.  Mal-location 
is  a  departure  of  the  entire  uterus  from  its  usual  relations. 
Mal-position  is  such  a  deviation  from  its  ordinary  attitude 
that  the  long  axis  of  the  uterus  has  changed  its  direction. 

The  mal-locations  are  ascent,  descent,  more  commonly 
known  as  prolapse,  antelocation,  retrolocation,  and  right  and 


Fig.  113. — Lateral  flexion  of  uterus. 


Fig.  114. — ^Lateral  version  of 
uterus. 


left  lateral  locations,  all  of  which  are  sufficiently  designated 
and  defined  by  their  names. 

In  mal-position  the  long  axis  of  the  uterus  may  be  either  a 
straight  or  curved  line;  when  the  former,  a  version  is  present, 
when  the  latter,  a  flexion. 

The  mal-positions  are  anteversion,  anteflexion,  retroversion, 
retroflexion,  left-lateral  version,  left-lateral  flexion,  right-lateral 
version,  and  right-lateral  flexion. 

Both  of  the  lateral  mal-locations  as  well  as  lateral  version 
and  lateral  flexion  are  relatively  of  little  importance,  and  the 
same  is  true  of  anteversion;  while  descent,  anteflexion,  retro- 


MAL-LOCATION   OF   THE  UTERUS  25 1 

version,  and  retroflexion  are  common  and  frequently  demand 
attention. 

In  any  of  the  displacements  the  uterus  may  be  movable  or 
fixed,  fixation  being  brought  about  most  commonly  by  adhesions 
to  neighboring  structures,  but  occasionally  by  tumor  pressure 
or  the  accumulation  of  blood,  pus,  etc.,  in  the  neighborhood; 
and  this  distinction  between  movable  and  fixed  displacement  is 
of  great  importance  from  the  standpoint  of  treatment. 

Mal-locations. — Ascent  is  produced  either  by  traction  upon 
the  uterus  from  above  or  upward  pressure  from  below.  Tumors 
growing  from,  or  adherent  to,  the  uterus  may  by  their  growth 
drag  the  organ  with  them  into  the  abdominal  cavity,  and  tumors 
which  grow  from  the  cervix  and  develop  low  in  the  pelvis  may 
push  it  upward,  as  may  such  an  accumulation  of  fluid  beneath 
it  as  is  present  in  pelvic  abscess,  hematocele,  and  hematocolpos. 
The  symptoms  presented  are  those  of  the  disease  which  pro- 
duces the  displacement,  the  latter  itself  producing  no  disturb- 
ance, and  the  vital  point  is  the  diagnosis  of  the  pathological 
condition  which  is  producing  the  displacement.  Ascent  ordi- 
narily is  recognized  by  the  absence  of  the  uterus  from  its  usual 
location,  and  the  presence  of  a  body  conforming  to  the  general 
outlines  of  the  uterus  higher  in  the  pelvis  or  even  in  the  abdom- 
inal cavity.  In  the  treatment  of  ascent  the  object  sought  is  the 
removal  of  the  cause,  whether  this  be  a  tumor,  pelvic  abscess, 
hematocele,  or  hematocolpos,  while  the  treatment  of  the 
displacement  is  but  a  secondary  incident. 

Posterior  and  lateral  dislocations  are  most  commonly  second- 
ary considerations  also,  and  are  produced  by  tumors  or  collec- 
tions of  fluid  which  crowd  the  uterus  away  from  that  portion  of 
the  pelvis  which  they  occupy,  or  by  adhesions  and  cicatrices 
which  draw  the  uterus  toward  that  quadrant  of  the  pelvis  in 
which  they  are  formed.  An  abnormal  anterior  location  is  some- 
times brought  about  by  relaxation  of  the  sacro-uterine  muscles 
when  this  is  associated  with  puerperal  injuries  to  the  vesico- 
vaginal septum,  thus  allowing  the  whole  uterus  to  drop,  but  this 


252  DISPLACEMENTS   OF   THE  UTERUS 

condition  does  not  demand  separate  consideration.  In  fact 
all  malpositions  except  descent  are  secondary  both  in  their 
etiology  and  treatment  to  the  causative  lesion,  and  the  recog- 
nition of  this  causative  lesion  is  the  really  important  problem. 

DESCENT  OR  PROLAPSUS  UTERI 

Prolapsus  uteri  is  usually  divided  into  three  degrees.  The 
first  degree  includes  descent  which  varies  from  a  merely  recog- 
nizable degree  to  that  in  which  the  cervix  lies  just  within  the 
vulva.  The  second  degree  implies  the  appearance  of  the  cervix 
at  the  vulva,  while  the  third  includes  all  instances  in  which  the 
uterus  either  partially  or  completely  escapes  from  the  vulva. 
This  arrangement  of  the  degrees  of  descent  is  not  exact  but 
it  has  the  merit  of  convenience. 

The  usual  causes  are  injuries  produced  by  child-birth.  In- 
juries to  the  levator  ani  muscles  and  their  fasciae  allow  the  poste- 
rior segment  of  the  anatomical  perineum  to  drop  away  from  the 
anterior,  and  thus  bring  the  long  axis  of  the  vagina  more  nearly 
parallel  to  that  of  the  uterus.  Injuries  to  the  anterior  segment 
of  the  perineum  allow  the  bladder  to  prolapse  and  draw  the  lower 
pole  of  the  uterus  forward,  so  that  the  long  axis  of  the  uterus  is 
more  nearly  parallel  to  that  of  the  vagina.  Lifting,  straining, 
standing,  or  walking  too  soon  after  labor  and  before  the  uterine 
supports  have  returned  to  their  normal  condition,  brings 
pressure  to  bear  upon  the  uterus  and  tends  to  drive  it  downward. 
Many  old  women  who  boast  that  they  always  resumed  their 
housework  two  or  three  days  after  labor  are  unaware  of  the 
fact  that  their  protruding  uteri  are  the  direct  result  of  such  hardi- 
hood. In  the  majority  of  instances  injury  to  the  levator  and  its 
fascia  posteriorly,  and  the  vesico-vaginal  septum  anteriorly, 
allows  the  bladder  to  protrude  and  draw  the  cervix  with  it,  so 
that  the  formation  of  a  cystocele  is  in  these  cases  the  first  step 
in  the  production  of  uterine  prolapse. 

Any  of  the  causes,  which  are  primarily  associated  with  injuries 


MAL-LOCATION   OF   THE  UTERUS 


253 


Fig.  115. — Ascent  of  uterus  due  to  fibroid  growing  from  posterior  uterine 
wall  which  carries  uterus  with  it.  On  bimanual  examination  this  might  be 
mistaken  for  a  retroflexion  with  a  tumor  in  the  anterior  uterine  wall. 


Fig.  116. — Descent  or  prolapsus  uteri.     "Second  degree." 


254  DISPLACEMENTS   OF   THE   UTERUS 

during  parturition,  are  followed  by  more  evidence  of  disability 
after  the  menopause,  because  at  this  time  physiological  atrophy 
of  the  muscles  of  the  pelvic  diaphragm  and  perineum  begins, 
and  this  process  eventually  removes  the  last  remnant  of  sup- 
port which  the  pelvic  contents  may  have  had. 

Lastly  we  must  recognize  that  there  are  a  limited  number  of 
cases  of  prolapse  occurring  in  nuUiparous  women,  and  that  they 
may  reach  an  extreme  degree.  These  cases  are  always  accom- 
panied by  congenital  retroversion  or  retroflexion  and  could  not 
occur  without  it. 

Prolapse  is  always  chronic  in  type  even  though  it  may  seem  to 
occur  suddenly.  In  these  instances  a  moderate  degree  of  unrec- 
ognized prolapse  was  previously  present,  and  the  acute  symptoms 
are  due  to  a  sudden  increase  in  the  degree  of  descent. 

Symptoms. — As  retroversion  is  necessarily  accompanied  by 
some  prolapse,  and  as  prolapse  beyond  a  barely  perceptible 
degree  also  presupposes  posterior  displacement,  it  frequently  is 
difficult  in  a  given  case  to  determine  whether  the  prolapse  is 
causing  the  patient's  symptoms,  or  whether  they  are  the  result 
of  the  associated  posterior  displacement. 

Actual  pain  is  a  more  frequent  symptom  of  the  early  than 
of  the  advanced  cases.  It  is  likely  that  in  early  cases  pain  is 
caused  by  traction  upon  the  sensory  nerves  contained  in  the 
supporting  structures  and  to  incarceration  of  the  uterus  in  the 
hollow  of  the  sacrum,  and  that  later,  as  the  prolapse  becomes 
more  complete,  the  nerves  are  over-stretched  and  the  uterus 
sinks  to  such  a  level  that  it  is  not  compressed,  so  that  pain  be- 
comes a  less  marked  feature.  In  extreme  prolapse  there  may 
be  no  pain  whatever,  and  the  patient  may  seek  relief  only  be- 
cause a  mass  protrudes  from  the  vulva  and  acts  as  a  mechanical 
nuisance.  Dragging  in  the  hypogastric  regions,  sacral  back- 
ache, and  a  feeling  of  weakness  in  the  entire  lower  abdomen  are 
usually  complained  of,  while  the  actual  association  of  cystocele 
with  prolapse  leads  to  incomplete  evacuation  of  the  bladder. 

Decomposition  of  urine  and  actual  cystitis  are  not  so  common 


PROLAPSE  OF  THE  UTERUS  255 

as  one  might  suppose,  but  bladder  irritability  and  incomplete 
relief  at  each  act  of  urination  are  frequent. 

Upon  examination  the  uterus  is  found  in  that  location  which 
corresponds  to  the  degree  of  prolapse  present.  In  the  lesser 
degrees,  which  are  merely  concomitants  of  retroversion  or 
retroflexion,  the  prolapse  is  likely  to  be  unrecognized  unless 
the  patient  is  examined  while  standing,  and  even  complete 
procidentia  might  sometimes  be  overlooked  if  the  patient  did 
not  insist  that  ''something  came  out."  If  the  uterus  protrudes 
constantly,  the  vaginal  walls  become  dry  and  parchment-like, 
and  the  odor  of  decomposing  urine  lingers  about  the  parts  in 
spite  of  the  utmost  care  on  the  part  of  the  patient.  Contact 
with  the  thighs,  with  the  clothing,  with  street  dust,  and  the 
irritation  of  decomposing  urine  on  the  protruding  cervix  and 
vaginal  wall  may  lead  to  superficial  erosion  and  occasionally 
to  deep  ulceration. 

It  is  hardly  possible  to  mistake  prolapse  for  any  other  con- 
dition once  the  external  uterine  orifice  is  detected  at  the  apex 
of  the  protruding  mass,  but  the  cystocele  which  usually  ante- 
dates it  is  often  mistaken  by  the  laity  for  a  prolapse  of  the  uterus 
itself.  Strangulation  of  the  prolapsed  uterus  is  a  rare  and  very 
dangerous  complication  which  may  be  confounded  with  chronic 
inversion,  but  here  again  the  location  of  the  external  orifice 
enables  one  to  differentiate  between  the  two.  Rarely,  hyper- 
trophic elongation  of  the  cervix  may  be  mistaken  for  prolapse, 
but  in  the  former  the  fundus  is  in  its  usual  location  while  in  the 
latter  it  is  absent  therefrom.  Replacement  of  the  uterus  and 
bi-manual  examination  is  always  necessary,  both  to  ascertain 
the  size  of  the  uterus  and  exclude  other  pelvic  complications. 

Treatment. — The  treatment  of  descent  may  be  either  mechan- 
ical or  operative.  In  the  mechanical  treatment  the  object 
sought  is  the  retention  of  the  uterus,  together  with  any  viscera 
which  may  prolapse  with  it,  at  or  near  their  proper  level  in  the 
pelvis. 

In  mild  cases  this  object  is  attained  by  mechanical  supjports 


256  DISPLACEMENTS   OF   THE  UTERUS 

which  retain  the  uterus  in  its  normal  position  of  anteversion, 
and  in  such  cases  the  treatment  resolves  itself  practically  into 
the  treatment  of  retroversion  and  retroflexion  by  means  of 
pessaries.  In  severe  degrees  of  prolapse  additional  support  is 
necessary  in  order  to  supply  the  deficiency  created  by  the  ab- 
sence of  a  normal  pelvic  diaphragm.  In  such  types,  represented 
by  prolapse  of  the  second  and  third  degree,  mechanical  treat- 
ment is  unsatisfactory  and  uncleanly,  but  it  frequently  must 
be  resorted  to  in  very  old  and  feeble  patients  and  in  those  who 
refuse  operation.  Pessaries  of  the  Smith-Hodge  and  ring  pat- 
terns sometimes  hold  the  uterus  in  place,  but  more  often  they  fail 
to  retain  it  within  the  body  because  the  relaxed  vaginal  orifice 
permits  their  ready  expulsion  upon  exertion,  and  in  this  event 
it  becomes  necessary  to  adjust  either  a  ball  or  cup  pessary. 
Ball  pessaries  must  be  so  large  that  they  cannot  be  readily 
expelled  as  they  depend  wholly  upon  their  size  for  their 
efficiency. 

The  soft  rubber  ball  is  more  satisfactory  than  the  hard  so  far 
as  its  retentive  power  is  concerned,  but  it  also  retains  the  uterine 
and  vaginal  discharge  and  unless  frequently  removed  and 
cleansed  sets  up  an  offensive  vaginitis. 

The  cup  pessary  has  a  vaginal  stem  and  is  retained  in  place 
by  means  of  perineal  straps  and  an  abdominal  belt  to  which 
the  straps  are  attached,  and  it  likewise  must  be  removed  daily 
for  cleansing.  Any  appliance  which  depends  for  its  usefulness 
upon  direct  pressure  against  the  prolapsing  viscera,  as  do  the 
ball  and  cup  pessaries,  must  be  used  with  great  care  as  ulcera- 
tion of  the  surface  with  which  it  is  in  contact  is  likely  to  ensue. 

Other  things  being  equal,  operative  measures  are  to  be  pre- 
ferred to  mechanical,  but  in  women  of  such  advanced  age  that 
their  lease  upon  life  is  short  at  best,  or  whose  health  is  so  bad 
that  operation  is  likely  to  be  dangerous,  mechanical  means  of 
retention  become  a  necessary  evil. 

Operative  procedures  are  satisfactory Jn  young  and  middle- 
aged  married  women  in  proportion  to  the  extent  to  which  they 


TREATMENT  OF  PROLAPSE  OF  THE  UTERUS     257 

conform  to  the  idea  that  prolapse  of  the  uterus  is  a  hernia  of  the 
uterus  through  the  pelvic  diaphragm.  In  old  women  whose 
sexual  organs  no  longer  are  functionally  active  the  problem 
of  retention  of  the  uterus  is  easy;  but  all  operations  fail  if  they 
are  performed  with  the  sole  object  of  removing  the  protruding 
mass,  because  the  hernial  orifice  permits  the  passage  of  other 
viscera  so  soon  as  the  uterus  is  out  of  the  way.  The  problem 
is  more  complicated  than  in  inguinal  hernia,  in  which  intra- 
abdominal pressure  serves  to  keep  the  canal  closed  if  the  sac 
is  removed  and  the  canal  restored  to  its  original  oblique  position. 
In  prolapse,  not  only  must  the  canal  be  restored  but  the  uterus 
must  be  returned  to  such  a  position  that  it  cannot  be  made  to 
protrude  by  intra-abdominal  pressure,  and,  if  this  is  not  possible, 
increased  resistance  must  be  supplied  by  anchoring  it  to  the 
anterior  abdominal  wall  above.  A  combination  of  operations  is 
usually  necessary  in  order  to  carry  out  the  foregoing  indications 
and  overcome  the  prolapse. 

Before  the  menopause  the  cervix  is  frequently  found  to  be 
lacerated  and  hypertrophied,  and  its  amputation  is  demanded 
as  the  first  step.  Next  the  cystocele  should  be  corrected  by 
some  method  which  does  not  shorten  the  anterior  vaginal 
wall,  and  this  is  best  accomplished  by  method  No.  2,  together 
with  Emmett's  denudation  which  tends  to  throw  the  cervix 
toward  the  hollow  of  the  sacrum;  then  the  posterior  segment 
of  the  perineum  is  restored  to  its  normal  position  under  the 
pubic  arch  by  method  No.  i.  No.  2,  or  No.  3  of  perineorrhaphy. 
This  may  be  all  that  is  necessary  in  mild  cases.  Ordinarily, 
however,  one  of  the  methods  of  shortening  the  round  Hgaments 
must  be  added  to  the  above  in  order  to  maintain  the  fundus 
in  its  normal  forward  position  of  anteversion. 

In  long-standing  cases,  in  which  the  muscles  of  the  pelvic  dia- 
phragm have  undergone  atrophy  from  disuse,  fijxation  of  the 
uterus  to  the  anterior  abdominal  wall  or  to  the  anterior  vaginal 
wall  becomes  necessary  in  addition  to  the  plastic  operation. 
Vaginal  fixation  is  advocated  by  some  authorities,  but  abdominal 
17 


258 


DISPLACEMENTS   OF   THE    UTERUS 


fixation  is  simpler  for  the  occasional  operator,  and  opening  the 
peritoneal  cavity  from  the  vagina  is  no  safer  as  regards  infection 
than  is  opening  it  through  the  anterior  abdominal  wall.  Neither 
shortening  the  round  ligaments,  nor  ventro-suspension,  are 
sufficient  in  marked  prolapse  because  the  normal  ligaments  are 
too  weak  to  do  more  than  hold  the  fundus  forward,  and  the 
third  hgament  which  is  formed  by  the  suspension  operation 


Fig.  117. — The  LeFort  operation. 
Anterior  denudation. 


Fig.  118. — The  LeFort  operation. 
Posterior  denudation. 


eventually  draws  out  to  a  filamentous  band  or  thread  which 
possesses  the  same  defect.  Fixation,  as  distinguished  from 
suspension,  overcomes  this  defect,  but  fixation  never  should  be 
performed  upon  women  who  are  subject  to  the  possibiUty  of 
pregnancy,  as  serious  difficulty  during  gestation  or  at  the  time 
of  labor  could  scarcely  be  avoided. 

This  combination  of  operations:  amputation  of  the  cervix, 
anterior  colporrhaphy,  perineorrhaphy,  and  ventro-fixation,  is 
especially  appUcable  to  that  class  of  cases  for  which  vaginal 


THE  LEFORT  OPERATION  FOR  PROLAPSE 


259 


hysterectomy  is  usually  advised,  and  it  has  the  advantage  over 
the  latter  operation  that  it  does  not  deprive  the  patient  of  any 
of  her  genital  organs.  In  women  who  are  past  the  menopause 
this  may  not  be  a  vital  consideration,  but  even  in  such  patients 
the  anteverted  fixed  uterus  assists  in  preventing  hernial  pro- 
trusion of  other  pelvic  viscera.  During  active  sexual  life  fixa- 
tion should  not  be  performed  unless  the  condition  is  so  extreme 
as  to  justify  sterilization  by  resection  of  the  tubes,  a  procedure 
which  is  less  grave  than  steriliza- 
tion by  removal  of  the  uterus. 

For  women  whose  age  or  do- 
mestic status  is  such  that  the 
functions  of  the  vagina  as  a  copu- 
lative organ  are  not  important,  a 
much  simpler  operative  combina- 
tion may  be  selected,  and  the 
vagina  can  be  narrowed  by  the 
LeFort  operation  to  such  an  ex- 
tent and  in  such  a  fashion  that 
protrusion  of  the  uterus  through 
it  is  impossible.  If  the  cervix  is 
hypertrophied  it  should  first  be 
amputated,  then  the  anterior  and 
posterior  vaginal  walls  are  de- 
nuded by  removal  of  a  longitu- 
dinal strip  3  cm.  wide,  extending 
from  the  cervico-vaginal  junction  to  the  posterior  surface  of  the 
symphysis  anteriorly,  and  over  a  corresponding  area  posteriorly. 
When  these  denuded  areas  are  united  to  each  other,  a  column  is 
formed  down  the  middle  of  the  vagina  with  a  narrow  channel  on 
either  side  through  which  the  secretions  can  escape,  and  inver- 
sion of  the  vagina  and  protrusion  of  the  uterus  are  effectually 
prevented  if  there  is  added  to  this  an  efficient  perineorrhaphy  for 
the  lowermost  support. 

Before  any  of   these  plastic  operations  are  performed  the 


Fig.  119. 


—The    LeFort    operation. 
Placing  sutures. 


26o 


DISPLACEMENTS   OF  THE   UTERUS 


vaginal  walls  should  be  restored  to  a  healthy  condition  by  re- 
placement of  the  uterus.  Its  retention  can  be  secured  by  rest  in 
bed  until  such  time  as  any  ulcerated  excoriated  areas  upon  the 
vaginal  mucosa  have  been  covered  by  normal  epithelium,  and 
this  is  effected  rapidly  when  the  surfaces  are  no  longer  subjected 
to  contact  with  the  air,  decomposing  urine,  etc.  Under  favor- 
able circumstances  an  operator  of  moderate  dexterity  can  com- 
plete all  the  necessary  work  at  one  sitting  and  avoid  the  distress 
of  repeated  anaesthesia. 

MAL-POSITIONS 

Anteversion. — Pathological  anteversion  may  be  produced  by 
any  cause  which  increases  the  weight  of  the  normally  anteverted 


Fig.  1 20. — Anteversion.     The  uterus  bisects  the  vagina  at  an  angle  too  acute. 


uterus  or  which  brings  increased  pressure  to  bear  upon  its 
posterior  surface.  Anteversion,  to  an  extent  which  would  be 
considered  pathological  under  other  circumstances,  is  thus 
physiologically  present  in  early  pregnancy  and  the  late  puer- 
perium  owing  to  the  increased  weight  of  the  uterus.     Fibroid 


ANTEVERSION  OF  THE  UTERUS 


261 


tumors,  sub-involution,  and  chronic  metritis  are  the  ordinary 
causes  of  pathological  anteversion  when  brought  about  by  the 
weight  of  the  uterus. 

The  symptoms,  aside  from  those  produced  by  pressure  upon 
the  bladder,  are  entirely  referable  to  the  causative  lesion.  The 
bladder  symptoms  are  increased  frequency  of  urination,  with 
possibly  some  burning  and  tenesmus.  The  diagnosis  is  estab- 
lished through  bi-manual  examination  by  which  the  fundus  is 


Fig.  121. — Anteflexion.     "The  cervix  and  body  meet  each  other  at  an  angle 
which  theoretically  is  sharper  than  it  should  be." 

found  pointing  forward  with  the  anterior  uterine  wall  too 
plainly  palpable  to  the  vaginal  finger,  while  the  uterus  is 
straight  and  the  cervix  points  back  toward  the  upper  portion 
of  the  sacrum. 

Treatment  of  anteversion,  per  se,  is  not  required  as  removal 
of  the  cause  is  sufficient  to  allow  spontaneous  cure  of  the  dis- 
placement. Pessaries  for  the  relief  of  anteversion  can  act  only 
by  exerting  pressure  on  the  fundus  through  the  anterior  vaginal 
wall  and  bladder,  and  thus  are  as  likely  to  increase  the  bladder 
irritability  as  they  are  to  allay  it. 


262  DISPLACEMENTS    OF   THE   UTERUS 

Anteflexion. — As  stated  at  the  opening  of  this  chapter,  a 
moderate  degree  of  anteflexion  is  normal,  and  it  is  likely  brought 
about  by  intra-abdominal  pressure  acting  upon  the  posterior 
surface  of  the  fundus,  while  contractions  of  the  bladder  draw 
the  cervix  forward  and  the  sacro-uterine  muscles  hold  the  mid- 
portion  of  the  uterus  fixed  in  position  a  short  distance  in  front 
of  the  sacrum.  It  is  conceivable  that  if  the  sacro-uterine  mus- 
cles are  short,  or  the  anterior  vaginal  wall  is  short,  or  if  the 
posterior  uterine  wall  is  soft  and  poorly  developed,  the  normally 
acting  forces  may  produce  an  exaggerated  degree  of  bending 
and  thus  lead  to  pathological  anteflexion. 

It  is  doubtful  whether  anteflexion  itself  causes  any  symptoms, 
aside  from  an  occasional  case  of  dysmenorrhea  when  the  flexion 
is  very  sharp,  and  possibly  sterility.  Extreme  anteflexion  may 
interfere  somewhat  with  the  outflow  of  menstrual  blood  if  clot- 
ting occurs,  and  that  type  of  anteflexion  in  which  the  fundus  is 
in  its  normal  position  while  the  cervix  is  drawn  sharply  up 
against  the  anterior  vaginal  wall,  may  be  productive  of  sterility 
because  it  removes  the  cervix  from  the  posterior  vaginal  fornix 
in  which  the  semen  naturally  collects. 

Anteflexion  of  the  soft  puerperal  uterus  may  lead  to  very 
serious  consequences  by  reason  of  the  accumulation  within  it  of 
lochial  discharge  which  readily  undergoes  decomposition,  the 
resulting  toxaemia  causing  chills,  fever,  and  other  evidences  of 
sapraemia.  Many  other  conditions,  especially  if  they  happen 
to  be  associated  with  dysmenorrhea,  are  illogically  attributed 
to  anteflexion.  Leucorrhea,  endometritis,  backache,  headache, 
hysteria,  and  neurasthenia  are  many  times  present  in  the  same 
patient  in  whom  an  anteflexion  is  found,  but  they  really 
should  be  considered  as  coincidences  only,  not  as  results  of 
the  anteflexion. 

Treatment  is  not  indicated  merely  because  the  cervix  and 
body  meet  each  other  at  an  angle  which  theoretically  is  sharper 
than  it  should  be,  and  interference  should  be  considered  when, 
and  only  when,  the  symptoms  complained  of  can  reasonably  be 


RETROVERSION  AND  RETROFLEXION  263 

attributed  to  the  flexion.  If  the  patient  has  severe  dysmenor- 
rhea which  is  cramp-like  in  character  and  associated  with  the 
expulsion  of  clots,  measures  should  be  instituted  to  overcome 
the  narrowing  which  may  be  presumed  to  exist  at  the  internal 
orifice.  If  in  addition  sterility  exists  and  there  is  no  tubal 
lesion  to  account  for  it,  some  method  of  treatment  should  be 
adopted  which  will  carry  the  external  uterine  orifice  further 
back  tow^ard  the  posterior  vaginal  cul-de-sac.  Thorough  dila- 
tation of  the  cervix  temporarily  overcomes  the  stenosis  and 
straightens  the  bend,  and  in  married  women  this  should  be 
accompanied  by  curettage  in  hopes  that  pregnancy  may  take 
place,  in  which  event  a  permanent  cure  can  be  anticipated 
through  the  nutritional  changes  which  occur.  Occasionally  it 
will  be  found  that  the  anterior  lip  is  very  short,  when  the  de- 
formity may  be  overcome  by  the  trivial  plastic  operation  of 
transverse  incision  of  the  vagina  just  above  the  anterior  cervico- 
vaginal  junction,  and  suture  of  this  incision  in  a  longitudinal 
direction. 

Dudley's  operation,  which  consists  in  splitting  the  posterior 
lip  of  the  cervix,  with  excision  of  a  wedge-shaped  section  from 
each  side  of  the  resulting  wound  so  that  all  raw  surfaces  may  be 
covered  with  mucosa  by  suturing,  is  a  logical  method  of  forming 
a  new  opening  so  far  posteriorly  that  it  approximates  the  loca- 
tion of  the  normal  cervical  outlet.  Acute  anteflexion  of  the 
puerperal  uterus  should  be  met  by  washing  out  the  retained 
lochial  discharge,  and  the  introduction  into  the  uterus  of  a  drain- 
age tube  of  such  caliber  and  thickness  as  to  prevent  recurrence. 

Retroversion  and  Retroflexion. — These  two  mal-positions  are 
so  similar  that  they  may  be  considered  together.  Their  only 
difference  lies  in  the  direction  of  the  uterine  axis,  which  in 
retroversion  is  a  straight  line,  while  in  retroflexion  it  is  curved 
or  broken  at  the  level  of  the  internal  uterine  orifice. 

Deficient  involution  of  the  uterus  and  its  ligaments  following 
labor,  together  with  injuries  to  the  pelvic  diaphragm,  is  the  most 
frequent  cause  of  backward  displacement.     Injury  to  the  pelvic 


264 


DISPLACEMENTS    OF   THE   UTERUS 


diaphragm  allows  the  heavy  uterus  to  descend,  while  imperfect 
involution  of  the  sacro-uterine  muscles  affords  an  opportunity 
for  the  cervix  to  drop  downward  and  forward.  In  consequence 
of  this  combination  the  fundus  falls  back  under  the  sacral  prom- 
ontory as  soon  as  it  has  undergone  sufficient  involution,  and 
intra-abdominal  pressure  then  acts  upon  the  anterior  face  of  the 
uterus,  with  a  fully  developed  retroversion  or  retroflexion  as  the 
result.  Retroflexion  is  more  common  than  retroversion  because 
the  soft  puerperal  uterine  wall  permits  of  bending  more  readily 


Fig.  122. — Retroversion.    The  axis  of  the  uterus  is  a  straight  line. 

than  its  supports  permit  of  further  descent.  Over-distension 
of  the  bladder  and  the  abdominal  binder  with  a  pad  under  it,  are 
contributory  causes  of  retrodisplacement  during  the  second  and 
third  puerperal  weeks,  and  early  resumption  of  corsets  during 
this  time  has  the  same  deleterious  effect. 

Congenital  retroversion  and  retroflexion,  and  backward  dis- 
placement of  the  fundus  associated  with  anteflexion  of  the  cer- 
vix, make  up  a  fairly  large  number  of  retrodisplacements,  which, 
while  small  in  proportion  to  those  due  to  the  injuries  and  sequelae 
of  labor,  is  by  no  means  so  inconsiderable  as  is  usually  taught. 


RETROVERSION  AND  RETROFLEXION 


265 


Acute  retroversion  and  flexion  are  sometimes  produced  by 
falls  upon  the  buttocks  and  back,  and  result  in  the  immediate 
onset  of  acute  symptoms. 

The  older  school  of  gynaecologists  laid  great  stress  upon  the 
importance  of  mechanical  disturbances  of  the  uterus,  while  at 
present  many  well-known  authorities  contend  that  posterior 
mal-positions  alone  and  by  themselves  provoke  no  symptoms 
whatever,  any  discomfort  being  referred  entirely  to  associated 
lesions  and  complications.     It  certainly  is  true  that  posterior 


Fig.  123. — Retroflexion. 


The  axis  of  the  uterus  is  a  curved  line,  concavity 
posteriorly. 


displacements  at  times  are  wholly  without  symptoms  and  un- 
known to  the  patient  unless  discovered  accidentally,  but  it  is 
just  as  certain  that  in  many  more  instances  correction  of  a 
retroversion  or  retroflexion  gives  relief  to  many  annoying  symp- 
toms, whether  these  symptoms  are  directly  due  to  the  displace- 
ment or  not.  Symptomless  retrodisplacement  is  most  likely 
to  be  found  in  virgins  and  nulliparous  married  women,  while 
displacement  without  discomfort  is  rare  in  child-bearing  women. 


266  DISPLACEMENTS    OF   THE   UTERUS 

Symptoms. — The  symptom  most  bitterly  complained  of  is  a 
sense  of  weakness  and  dragging  in  the  lower  abdomen,  par- 
ticularly if  the  patient  stands  a  great  deal.  Walking  usually 
provokes  less  discomfort  than  standing.  Severe  sacral  back- 
ache is  common,  and  leucorrhea  is  almost  always  present. 
Increased  menstruation,  sometimes  so  profuse  as  to  be  menor- 
rhagic  in  character,  is  also  common.  Rather  severe  pain  con- 
tinued for  several  days  and  subsiding  spontaneously,  beginning 
without  known  reason  and  leaving  in  its  wake  a  sensation  of 
soreness  over  the  entire  lower  abdomen,  is  a  pronounced  feature 
of  many  cases  and  gives  weight  to  the  view  that  much  of  the 
pain  is  congestive  in  character. 

Vaginal  examination  shows  the  cervix  to  be  nearer  the  vaginal 
outlet  than  normal,  but  the  direction  in  which  it  points  is  unim- 
portant. Bi-manual  examination  (always  with  the  bladder 
and  rectum  empty)  reveals  the  absence  of  the  fundus  from  its 
normal  location  behind  the  symphysis  and  its  presence  poste- 
riorly. If  the  patient  is  very  spare  and  the  abdominal  muscles 
relaxed,  the  entire  uterus  may  be  grasped  between  the  finger  in 
the  vagina  and  the  hand  on  the  abdomen,  and  its  shape  and  size 
accurately  determined.  With  thick  resistant  abdominal  walls 
this  is  impossible,  and  the  diagnosis  must  then  be  based  upon 
the  absence  of  the  uterus  from  any  portion  of  the  pelvis  excepting 
the  recto-uterine  excavation,  and  the  presence  therein  of  a  body 
whose  posterior  surface  corresponds  to  that  of  the  uterus. 
Exceptionally  it  may  be  necessary  to  pass  a  sound,  but  ordina- 
rily this  is  not  only  unnecessary  but  fraught  with  enough  danger 
to  make  it  inadvisable.  An  attempt  should  always  be  made  to 
ascertain  whether  the  uterus  is  movable  or  fixed.  If  it  can  be 
brought  forward  readily  and  does  not  at  once  return  to  its  origi- 
nal position,  adhesions  are  probably  absent,  but  in  many  cases 
this  is  accomplished  with  difficulty  or  not  at  all,  even  when  there 
are  no  adhesions.  Sometimes  one  or  both  ovaries  are  palpable 
behind  the  uterus  and  are  found  to  be  freely  movable,  when  the 
uterus  also  may  be  presumed  to  be  free,  as  the  well  nigh  universal 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION    267 

cause  of  uterine  fixation  is  localized  peritonitis  resulting  from 
salpingo-oophoritis.  Assumption  of  the  knee-chest  position  at 
intervals  for  several  days  usually  will  make  it  possible  to  replace 
the  retroposed  non-adherent  uterus  without  difficulty,  even  if 
the  first  effort  fails. 

Occasionally  a  fibroid  in  the  posterior  uterine  wall  simulates 
a  retroposed  uterus  to  the  vaginal  touch,  but  persistence  in  the 
examination  will  enable  one  to  map  out  the  fundus  anteriorly. 
When  the  conditions  are  reversed  and  a  small  fibroid  nodule  is 
present  in  the  anterior  uterine  wall  while  the  fundus  is  posterior, 
a  positive  diagnosis  may  be  difficult  to  establish,  but  if  two 
bodies  can  be  felt  the  actual  position  of  the  uterus  is  subordinate 
in  importance  to  the  fact  that  a  tumor  is  present. 

When  a  large  mass  of  exudate  fills  the  pelvis  it  may  be  quite 
impossible  to  make  out  the  position  of  the  uterus,  but  again  the 
position  of  the  uterus  is  of  no  especial  importance  when  com- 
pared to  the  damage  wrought  upon  the  tubes  and  ovaries  by  the 
infection  which  caused  the  exudate.  Fixation  of  the  uterus 
always  exists  under  these  conditions,  and  may  be  assumed  to 
be  present  when  there  has  been  enough  salpingitis  to  leave 
palpably  thickened  tubes. 

Treatment. — The  treatment  of  the  uterus  which  is  adherent 
posteriorly  is  the  treatment  of  the  condition  which  produced  the 
adhesions.  No  attention  need  be  given  the  displacement,  per 
se,  but  the  primary  disease  demands  treatment.  If  an  opera- 
tion is  necessary  for  the  latter  the  mechanical  disturbance 
should  be  corrected  at  the  same  time.  The  forcible  breaking 
up  of  adhesions  under  anaesthesia  is  not  always  successful  and 
is  far  more  hazardous  than  an  abdominal  incision.  Those  who 
frequently  open  the  abdomen  are  aware  of  the  fact  that  pus 
foci  exist  which  were  wholly  unsuspected,  and  the  density  of  the 
adhesions  is  often  so  great  that  damage  to  the  bowel  occurs 
even  when  they  are  separated  in  plain  view.  It  is  difficult  to 
imagine  a  combination  of  circumstances  which  would  justify 


268  DISPLACEMENTS    OF   THE   UTERUS 

the  forcible  breaking  up  of  adhesions  and  replacement  of  the 
uterus  without  an  open  incision. 

Acute  retroversion  or  retroflexion  demands  immediate  re- 
placement and  this  can  usually  be  accomplished  bi-manually. 
One  or  two  fingers  are  first  inserted  behind  the  cervix  with 
which  the  body  of  the  uterus  is  lifted  from  its  bed.  The  hand 
which  is  upon  the  abdomen  then  endeavors  to  grasp  the  fundus 
and  draw  it  forward,  or  at  least  maintain  the  advantage  already 
gained,  while  the  vaginal  fingers  are  shifted  to  the  front  of  the 
cervix  and  push  it  posteriorly  toward  the  sacrum.  If  this 
maneuver  fails  the  patient  should  be  placed  in  the  knee-chest 
posture  and  the  cervix  drawn  down  by  vulsellum  forceps  as  far 
as  possible  without  causing  pain.  A  large  piece  of  cotton  is 
then  crowded  against  the  posterior  vaginal  fornix  in  an  endeavor 
to  push  the  fundus  forward,  after  which  the  patient  should 
slowly  resume  the  dorsal  position,  when  it  will  usually  be 
found  that  bi-manual  reposition  can  be  accomplished  without 
difficulty.  Opening  the  anus  with  a  small  speculum  while  the 
patient  is  in  the  knee-chest  position  will  sometimes  give  assist- 
ance by  allowing  the  rectum  to  fill  with  air,  and  it  is  wise  to  do 
this  before  having  the  patient  turn  upon  her  back  preparatory 
to  bi-manual  reposition.  Owing  to  extreme  sensitiveness,  or 
thick  or  rigid  abdominal  walls,  these  manipulations  may  fail  to 
accomplish  their  purpose,  and  as  immediate  relief  is  demanded 
in  acute  retrodisplacements  anaesthesia  is  indicated,  under 
which  any  movable  displacement  can  be  easily  overcome.  In 
acute  posterior  displacement  the  uterus  ordinarily  retains  the 
correct  position  once  replacement  has  been  accomplished,  so 
that  no  mechanical  support  is  necessary. 

These  directions  for  replacing  the  uterus  serve  equally  well 
in  chronic  cases  of  mobile  retroversion  or  retroflexion,  excepting 
that  anaesthesia  is  rarely  called  for  inasmuch  as  there  is  no  need 
for  immediate  replacement.  As  before  mentioned,  if  the  knee- 
chest  posture  is  assumed  for  five  or  ten  minutes  twice  a  day,  one 
will  be  able  to  replace  the  uterus  a  few  days  later  should  the  first 


RETROVERSION  AND   RETROFLEXION:   PESSARIES  269 

attempt  result  in  failure.  In  giving  instructions  for  this,  care 
should  be  taken  that  the  patient  understands  the  position,  and 
that  it  is  not  effectual  unless  all  constricting  bands  are  removed 
from  about  the  waist.  Reposition  with  the  sound  is  never 
necessary  and  is  more  dangerous  than  the  displacement  for 
whose  correction  it  is  sometimes  advised. 

In  the  management  of  chronic  movable  retrodisplacements, 
a  distinction  should  be  made  between  those  patients  who  are 
seen  within  a  few  months  after  labor,  and  those  who  either 
never  have  been  pregnant,  or  in  whom  the  displacement  has 
not  been  discovered  until  a  year  or  more  has  elapsed  since 
delivery.  In  the  former  class  the  patient  should  be  given  the 
benefit  of  postural  and  mechanical  treatment  in  the  hope  that 
sufi&cient  involution  may  yet  be  secured  to  effect  a  spontaneous 
cure.  The  author  himself  is  convinced  that  if  postural  treat- 
ment is  efficiently  and  intelligently  carried  out  it  will  cure  as 
many  cases  as  will  the  pessary,  and  it  has  the  advantage  that 
it  does  not  require  the  constant  attention  of  the  physician. 
Postural  treatment  does  away  with  the  frequent  repetition  of 
examinations  which  serve  to  keep  the  mind  of  the  patient 
fixed  on  her  genital  organs,  and  she  accepts  the  treatment  as  a 
form  of  gymnastic  exercise. 

Mechanical  treatment  with  the  pessary,  however,  is  sometimes 
necessary,  and  in  using  it  a  few  cardinal  facts  should  be  borne 
in  mind.  The  pessary,  first  of  all,  is  but  an  instrument  which 
is  designed  to  hold  the  cervix  in  its  proper  position  an  inch  or 
thereabouts  in  front  of  the  sacrum,  and  it  should  be  used  only 
after  the  uterus  is  replaced,  not  before.  Again,  the  pessary  acts 
as  a  lever  and  not  by  reason  of  its  size.  The  posterior  portion 
of  the  lateral  bars  is  the  short  arm  of  the  lever,  the  fulcrum  is 
the  posterior  vaginal  wall,  and  the  longer  portion  of  the  lateral 
bars  is  the  long  arm  of  the  lever  which  extends  to  the  level  of 
the  posterior  surface  of  the  symphysis.  The  pessary  cannot 
act  if  the  cervix  is  so  deeply  torn  that  the  posterior  bar  does  no 
more  than  draw  the  lips  apart,  nor  if  the  pelvic  floor  is  so  dam- 


270  DISPLACEMENTS    OF   THE   UTERUS 

aged  that  the  posterior  vaginal  wall  offers  no  support.  The 
pessary  should  not  cause  the  slightest  discomfort.  A  prolapsed 
ovary  frequently  fails  to  return  to  its  normal  position  when  the 
uterus  is  replaced,  and  in  this  event  it  may  be  pinched  by  the 
posterior  bar  and  give  rise  to  severe  pain.  Before  dismissing 
the  patient  it  is  wise  to  have  her  walk  about  the  room  in  order  to 
be  sure  that  no  discomfort  is  produced  by  the  change  of  position 
and  consequent  shifting  of  intra-abdominal  pressure.  Finally, 
the  pessary  should  be  removed  at  least  once  in  three  months 
and  be  allowed  to  remain  out  for  several  days,  for  the  double 
purpose  of  preventing  ulceration  of  the  vaginal  walls  and  ascer- 
taining whether  the  uterus  retains  its  normal  position  in  the 
absence  of  artificial  support.  Should  the  uterus  be  found  to 
remain  in  position  a  permanent  cure  is  still  uncertain  and  the 
pessary  should  be  worn  at  least  three  months  longer. 

It  is  rarely  necessary  to  go  outside  the  Smith-Hodge  and  ring 
types  of  pessary  in  order  to  secure  a  well-fitting  instrument  for 
any  case  which  is  suitable  for  mechanical  treatment.  The 
approximate  length  is  ascertained  by  inserting  one  finger  into  the 
posterior  vaginal  fornix  and  measuring  the  distance  from  this 
point  to  one  just  behind  the  symphysis.  The  width  is  gauged 
by  the  general  size  of  the  vagina.  It  should  be  said,  however, 
that  the  longer  one  practises  the  more  he  is  inclined  to  resort  to 
a  simple  ring  whose  longitudinal  and  transverse  diameters  are,  of 
course,  the  same. 

The  pessary  is  inserted  by  depressing  the  perineum  with  one 
forefinger,  while  the  other  hand  insinuates  the  support  obliquely 
through  the  vulvar  cleft  in  order  to  avoid  pressure  upon  the 
sensitive  urethral  orifice.  After  passing  the  vulva  it  is  turned 
into  that  position  which  it  is  expected  to  occupy,  when  the 
posterior  bar  will  be  found  in  front  of  the  cervix.  By  inserting 
one  finger  between  the  anterior  bar  and  perineum,  and  then 
through  the  lumen  of  the  pessary  and  over  the  posterior  bar,  it 
is  hooked  downward  and  backward  and  readily  slips  into  place. 


RETROVERSION  AND   RETROFLEXION:   PESSARIES  27 1 

A  pessary  should  never  fit  so  tightly  that  the  finger  cannot  be 
inserted  between  it  and  the  vaginal  wall  in  any  direction. 

In  removing  the  pessary,  slight  downward  traction  should  be 
made  upon  its  anterior  end.  It  is  then  rotated  into  an  oblique 
position  and  comes  away  without  difficulty.  The  patient  should 
be  shown  the  proper  method  of  removing  the  pessary  and  in- 
structed to  do  so  at  once  if  at  any  time  it  causes  pain.  If 
retroversion  or  retroflexion  is  discovered  accidentally  years 
after  labor,  or  if  pregnancy  has  never  occurred,  the  propriety  of 
any  sort  of  treatment  is  doubtful  unless  there  are  symptoms 
definitely  referable   to   the   displacement.     Most  women   are 


Fig.  124. — Smith  and  ring  pessaries.     "It  is  rarely  necessary  to  go  outside  the 
Smith-Hodge  or  ring  type  of  pessary." 

exceptionally  susceptible  to  the  suggestion  of  anything  wrong 
with  the  genital  organs,  and  the  knowledge  that  they  have  even  a 
symptomless  displacement  is  Ukely  to  do  them  more  harm  than 
its  treatment  will  do  good. 

Old  displacements  of  any  sort  are  rarely  cured  by  mechanical 
treatment,  and  this  fact  should  be  plainly  stated  to  those  pa- 
tients in  whom  a  displacement  seems  to  be  responsible  for 
symptoms;  but  mechanical  treatment  for  a  short  time  will 
determine  more  definitely  than  anything  else  whether  or  not 
the  symptoms  complained  of  are  due  to  the  displacement. 
For  this  reason  the  pessary  has  a  wide  field  of  usefulness  as  a 
diagnostic  instrument.  If  relief  is  obtained  by  its  use,  the 
patient  should  be  told  that  she  either  must  wear  it  indefinitely 


272  DISPLACEMENTS   OF   THE  UTERUS 

or  submit  to  an  operation,  and  she  should  be  allowed  to  decide 
which  method  shall  be  adopted.  Retroposition  without  marked 
descent  is  entirely  negligible  in  women  who  have  passed  the 
menopause,  and  no  interference  is  necessary.  ^ 

Operation  is  to  be  advised  for  retroversion  and  retroflexion; 
First,  when  the  uterus  is  fixed,  in  which  event  correction  of  the 
displacement  is  an  adjunct  to  whatever  operation  is  made  neces- 
sary by  the  primary  disease ;  second,  for  chronic  movable  displace- 
ment in  multiparas,  when  the  patient  deliberately  elects  operation 
in  preference  to  pessary  treatment  and  there  is  reasonable 
ground  for  a  belief  that  the  displacement. is  responsible  for  the 
symptoms  presented;  third,  it  is  to  be  advised  with  caution  for 
congenital  displacement,  as  nature  has  many  times  adjusted 
conditions  to  the  abnormal  position  of  the  uterus  and  the  pa- 
tient may  be  made  worse  by  an  operation  which  fixes  the  uterus 
in  a  theoretically  normal  position.  It  is  understood  that  in- 
juries to  the  cervix  or  pelvic  floor  are  to  be  corrected  previous 
to  or  at  the  time  the  displacement  itself  is  attacked. 

Operative  procedures  are  of  three  kinds.  The  first  shortens 
the  normal  ligamentous  supports  of  the  uterus;  the  second  adds 
a  new  ligament;  and  the  third  definitely  fixes  the  uterus  in  a 
position  of  anteversion. 

In  the  first  class  are  to  be  placed  all  of  the  methods  of  short- 
ening the  round  ligaments,  as  well  as  the  much  more  difficult 
operation  of  shortening  the  sacro-uterine  ligaments.  In  the  sec- 
ond is  the  popular  Kelly  suspension  operation.  In  the  third 
are  to  be  found  all  methods  by  which  fixation  to  the  an- 
terior abdominal  wall  is  accomplished,  as  well  as  the  various 
forms  of  vaginal  fixation. 

The  operation  to  be  selected  for  the  individual  case  is  de- 
pendent upon  certain  elemental  considerations,  and  no  one 
operation  is  suitable  for  all  retrodisplacements  under  all 
circumstances. 

Of  the  round-ligament  operations  the  Alexander  may  be  con- 
sidered when  the  degree  of  prolapse  is  negligible  and  the  tubes 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION   273 

and  ovaries  are  perfectly  healthy.  It  has  the  advantage  of  not 
opening  the  peritoneal  cavity  and  it  does  not  interfere  with 
future  pregnancy  or  labor.  On  the  other  hand,  it  necessitates 
two  incisions  which  are  placed  in  that  portion  of  the  abdominal 
wall  most  prone  to  suppuration,  and  suppuration  may  lead  to 
the  subsequent  development  of  hernia. 

The  Gilliam  operation,  like  the  Alexander,  utilizes  the  strong- 
est part  of  the  ligaments,  but  it  involves  a  very  undesirable 
amount  of  handling  of  the  subcutaneous  tissue.  It  is  to  be 
remembered  that  no  operation  can  be  made  absolutely  aseptic, 
and  that  the  fatty  and  muscular  tissues  of  the  abdominal  wall 
are  more  readily  infected  than  the  peritoneum  although  infec- 
tion of  the  latter  is  more  dangerous  to  life  if  it  does  take  place. 
The  Gilliam  presents  an  advantage  which  is  inherent  in  all  intra- 
peritoneal operations  in  that  it  may  be  performed  as  an  adjunct 
to  operations  upon  the  tubes  and  ovaries.  Of  the  methods  of 
folding  or  shortening  the  ligaments  intra-peritoneally,  the  only 
one  worth  considering  is  that  which  folds  them  behind  the 
uterus.  Its  one  defect  Hes  in  the  fact  that  the  weaker  outer 
ends  of  the  ligaments  are  utiHzed  for  support,  but  this  probably 
is  more  than  compensated  for  by  the  mechanical  advantage 
which  is  gained  by  making  traction  upon  the  uterus  from  its 
posterior  surface,  thus  tending  to  throw  it  so  far  forward  that 
intra-abdominal  pressure  assists  materially  in  retaining  it  in 
position.  None  of  the  round  ligament  operations  are  satis- 
factory when  there  is  marked  prolapse,  but  none  of  them  inter- 
fere with  subsequent  pregnancy. 

Ventro-sus pension  is  satisfactory  as  an  adjunct  to  operations 
upon  the  tubes  and  ovaries  when  these  operations  themselves 
are  such  as  to  induce  sterility.  It  should  not  be  done  in  child- 
bearing  women,  and  even  in  those  who  are  sterile  it  is  not  so 
advantageous  as  posterior  round-ligament  suspension,  as  the 
band  produced  by  the  former  has  been  the  cause  of  intestinal 
obstruction  in  many  instances. 

Ventro-fixation  is  never  needed  for  posterior  displacement 
18 


2  74  DISPLACEMENTS   OF   THE   UTERUS 

alone,  but  if  posterior  displacement  is  accompanied  by  marked 
prolapse  in  women  who  are  past  the  menopause,  or  if  displace- 
ment is  associated  with  such  serious  inflammatory  lesions  that 
removal  of  the  tubes  and  ovaries  is  necessary,  ventro-fixation 
is  the  operation  of  choice.  Ventro-fixation  is  preferable  to 
vaginal  hysterectomy  in  the  third  degree  of  prolapse,  and  then 
it  should  be  associated  with  the  proper  plastic  procedures,  and 
in  women  of  child-bearing  age  with  resection  of  the  tubes. 
To  put  the  matter  in  another  way,  vaginal  hysterectomy  induces 
sterility,  and  in  prolapse  of  so  serious  a  nature  as  to  justify 
sterilization,  fixation  with  artificially  induced  sterility  is  the 
more  satisfactory  of  the  two. 

INVERSION    or    THE    UTERUS 

Acute  inversion  of  the  uterus  usually  occurs  during  the  third 
stage  of  labor,  at  which  time,  if  the  placenta  is  firmly  adherent 
near  the  fundus  of  the  uterus,  traction  upon  the  cord  may  drag 
the  fundus  through  the  cervix.  Acute  inversion  may  also  be 
produced  during  the  vaginal  removal  of  an  intra-uterine  myoma, 
traction  upon  a  pedunculated  tumor  attached  to  the  fundus 
sometimes  inverting  the  latter  through  the  cervix.  As  the  fun- 
dus is  larger  than  the  remainder  of  the  uterine  body,  it  tends 
to  become  more  completely  and  permanently  inverted  by  the 
elastic  constriction  of  the  muscular  cervix  which  now  sur- 
rounds the  upper  narrow  portion,  as  well  as  by  the  oedema 
produced  through  interference  with  the  return  circulation 
which  is  brought  about  in  the  same  manner. 

Fortunately,  acute  inversion  taking  place  during  vaginal 
myomectomy  is  partial  only,  and  its  principal  importance  lies 
in  the  possibility  that  the  uterine  wall  may  be  perforated  or 
ruptured  when  the  pedicle  of  the  tumor  is  cut  through  unless 
the  special  technique  described  under  vaginal  myomectomy  is 
followed. 

Inversion  during  the  last  stage  of  labor  is  an  obstetric  acci- 


INVERSION  OF  THE  UTERUS 


275 


dent  whose  diagnosis  and  treatment  are  described  in  text-books 
on  that  subject,  and  chronic  inversion  usually  is  due  to  a  failure 
to  diagnose  the  accident  at  the  time  of  its  occurrence,  the  uterus 
remaining  in  its  inverted  condition  if  the  patient  survives. 

The  symptoms  of  chronic  inversion  may  be  trivial;  menor- 
rhagia,  metrorrhagia  and  leucorrhea,  with  or  without  constant 
pelvic  discomfort,  being  the  usual  complaints. 

On  digital  examination  the  vagina  is  found  to  contain  a  firm, 
but  elastic  rounded  body  which  bleeds  readily,  and  whose  sur- 


FiG.  125. — Inversion  of  the  uterus.     Sagittal  section. 

face  is  velvety  to  the  touch.  If  the  finger  can  be  insinuated 
between  this  body  and  the  vaginal  wall  the  ring  of  the  cervix 
can  be  made  out,  but  at  no  point  within  the  circumference  of  the 
external  uterine  orifice  is  it  possible  to  insert  the  finger  more 
than  a  short  distance  without  coming  into  contact  with  the 
uterine  wall. 

On  bi-manual  examination  the  fundus  is  found  to  be  absent 
from  its  usual  location,  and  if  the  abdominal  wall  is  very  thin 
and  relaxed,  a  depression  in  the  center  of  the  supra- vaginal  cervix 


276 


DISPLACEMENTS   OF   THE   UTERUS 


may  be  felt  by  the  abdominal  hand.  Inspection  through  the 
speculum  shows  a  red  or  bluish  rounded  body  in  the  upper  por- 
tion of  the  vagina,  and  the  orifices  of  the  tubes  may  possibly  be 


Fig,  126. — Inversion  of  uterus.  Drawing  from  specimen,  superior  surface, 
showing  cup  shaped  depression  into  which  one  tube  is  partially  drawn.  Tube 
contained  pus.     The  other  tube  and  ovary  were  not  removed. 


found  if  preceding  manipuhition  has  not  been  productive  of  too 
much  hemorrhage. 

Chronic  inversion  of  the  uterus  can  scarcely  be  mistaken  for 
anything  excepting  a  partially  or  completely  expelled  intra- 


TREATMENT  OF  INVERSION  OE  THE  UTERUS      277 

uterine  myoma,  and  when  the  two  co-exist  a  diagnosis  may  be 
impossible.  Most  frequently,  however,  chronic  inversion  is  a 
sequel  of  labor,  and  the  diagnosis  is  estabHshed  by  the  absence 
of  the  fundus  from  its  usual  location  and  the  presence  within 
the  vagina  of  a  body  corresponding  in  shape,  size,  and  appear- 
ance to  the  uterus  turned  wrong  side  out. 

Treatment. — A  great  variety  of  methods  of  treatment  have 
been  devised,  some  of  which  date  back  to  the  pre-antiseptic  era 
and  need  no  consideration  at  the  present  time. 

Practically,  three  methods  are  available  and  may  be  tried  in 
succession:  manual  replacement,  deep  incision  of  the  cervix 
followed  by  manual  replacement,  and  hysterectomy.  If  the 
case  is  recent  and  but  few  adhesions  have  formed  between  the 
adjacent  peritoneal  surfaces  of  the  uterus,  or  between  these  peri- 
toneal surfaces  and  the  tubes  and  ovaries  which  are  drawn  into 
the  depression,  manual  replacement  under  deep  anaesthesia  may 
succeed,  the  oedematous  uterus  being  squeezed  in  the  palm  of 
the  hand  while  the  fingers  and  thumb  make  pressure  on  the 
cervico-corporeal  junction.  Considerable  patience  is  necessary, 
and  pressure  upon  the  fundus  and  body  of  the  uterus  must  be 
persistent  in  order  to  diminish  the  oedema  before  the  uterus 
can  be  reduced  to  a  size  sufficiently  small  to  permit  of  its  return 
through  the  cervical  ring. 

Should  this  fail  the  cervix  may  be  incised  to  or  through  the 
internal  os  both  anteriorly  and  posteriorly,  and  manual  replace- 
ment be  again  attempted,  but  care  must  be  taken  that  these 
incisions  do  not  extend  into  the  peritoneal  cavity  as  the  endo- 
metrium is  certain  to  be  infected  by  its  long-continued  exposure 
in  the  vagina.  Should  the  posterior  incision  accidentally  pass 
into  the  abdominal  cavity,  the  cervical  incision  should  be  closed 
as  soon  as  the  uterus  is  returned  and  the  recto-uterine  excava- 
tion be  drained  into  the  vagina.  Failure  of  these  manipulations 
to  secure  replacement  should  lead  to  hysterectomy,  whether 
vaginal  or  abdominal  being  dependent  upon  the  freedom  of 
access  to  the  vaginal  vault. 


278  DISPLACEMENTS    OF   THE   UTERUS 

Prolonged  efforts  at  the  preservation  of  an  inverted  uterus 
is  a  loss  of  time  and  leads  to  bruising  and  diminished  vitality  of 
the  endometrium  which  in  turn  may  give  rise  to  a  disastrous 
pelvic  infection,  so  that  radical  measures  are  likely  to  prove 
more  conservative  unless  the  displacement  is  of  recent  occur- 
rence and  the  endometrium  is  reasonably  healthy.  It  is  obvious 
that  a  greater  effort  should  be  made  to  save  the  uterus  in  a  young 
woman  than  in  one  who  is  older  even  though  more  risk  is  in- 
volved, and  the  nearer  the  patient  is  to  the  menopause  the  more 
clear  is  the  indication  for  radical  operation. 

PERFORATION    OF    THE    UTERUS 

Generally  speaking,  perforation  of  the  uterus  is  an  ac- 
cident. It  may  take  place  during  examinations  with  the 
sound,  efforts  at  instrumental  replacement  of  the  uterus,  intra- 
uterine operations,  or  the  attempted  induction  of  criminal 
abortion. 

The  results  of  the  accident  are  dependent  upon  three  factors : 
First,  the  size  of  the  perforation;  second,  the  sterility  or  other- 
wise of  the  uterine  cavity  and  the  instrument  inflicting  the  in- 
jury; third,  the  associated  damage  to  other  abdominal  viscera. 

A  perforation  which  is  inflicted  with  a  clean  sound  or  similar 
small  blunt  instrument,  passed  through  a  non-infected  uterine 
cavity,  and  withdrawn  without  damage  to  the  intestine,  is  not 
likely  to  be  followed  by  serious  consequences. 

A  large  perforation  may  lead  to  intestinal  prolapse  and  stran- 
gulation. 

Perforation  with  an  unclean  instrument,  or  perforation  with  an 
instrument  previously  sterilized,  but  introduced  through  an 
infected  cervix  or  uterine  cavity,  may  lead  to  local  or  general 
septic  peritonitis.  Perforation  with  a  long  sharp  instrument, 
even  though  it  be  small  and  clean,  may  mean  damage  to  the 
intestine  or  bladder  with  contamination  of  peritoneum,  virulent 
infection,  and  death. 


PERFORATION  OF  THE  UTERUS  279 

The  most  deplorable  instances  of  this  accident  are  those  which 
occur  during  curettage  of  a  pregnant  or  recently  pregnant 
uterus.  The  softness  of  the  uterine  wall  during  pregnancy- 
leads  to  extensive  laceration,  and  the  uterine  cavity  is  so  large 
that  the  operator  may  not  be  aware  of  the  accident  until 
serious  or  fatal  damage  has  been  inflicted  upon  the  intestine 
or  its  mesentery. 

Symptoms  and  Diagnosis. — If  the  patient  is  not  anaesthetized 
she  may  experience  severe  pain  when  the  instrument  impinges 
upon  the  parietal  peritoneum  or  mesentery,  otherwise  there 
may  be  no  immediate  symptoms.  The  operator  should  be 
aware  of  the  fact  that  his  instrument  has  passed  beyond  the 
limits  of  the  uterine  cavity.  Should  any  suspicion  arise  that 
this  is  the  case,  the  instrument  should  be  manipulated  very 
carefully  until  it  is  definitely  determined  whether  or  no  its 
extremity  has  gone  through  the  uterine  wall. 

Sudden  relaxation  of  the  uterus  under  anaesthesia  is  not  un- 
common, but  its  walls  are  always  present  and  may  be  felt,  while 
perforation  with  any  ordinary  instrument  permits  it  to  be 
pushed  on  indefinitely  without  meeting  resistance. 

Reported  instances  of  the  introduction  of  sounds  through 
the  uterine  cavity  into  the  tubes  were  more  likely  either  per- 
foration or  sudden  relaxation. 

Treatment. — Perforation  of  a  sterile  uterus  with  a  sterile 
sound  or  small  dull  curette  needs  no  treatment  if  the  accident 
is  recognized.  If  there  is  any  reason  to  believe  that  the  per- 
foration is  larger  than  the  instrument  which  produced  it,  the 
uterus  should  be  packed  with  gauze,  but  under  no  circumstances 
should  it  be  irrigated.  On  two  occasions  the  author  has  seen 
the  uterus  unnecessarily  removed  because  a  trivial  perforation 
had  been  discovered. 

Should  the  injury  to  the  uterine  wall  be  at  all  extensive  or 
the  uterus  be  infected,  or  if  there  is  any  possibility  of  damage 
to  the  intestine  or  bladder,  the  abdomen  must  be  opened  and 
the  conditions  which  are  found  treated  upon  their  merits.     If 


28o  DISPLACEMENTS    OF   THE   UTERUS 

the  accident  is  not  discovered  until  after  the  uterus  has  been 
irrigated  or  swabbed  with  antiseptics,  the  abdomen  must  be 
opened,  the  irrigating  fluid  removed,  the  perforation  sewn  up, 
and  the  pelvic  cavity  filled  with  saline  solution  to  minimize  the 
irritating  effect  of  the  antiseptic. 

Perforation  with  a  dirty  instrument,  or  with  a  clean  instru- 
ment through  an  infected  uterus,  calls  for  immediate  opening 
of  the  abdomen  with  careful  cleansing  of  the  pelvic  cavity. 
The  perforation  may  be  closed  if  it  is  small  and  the  cleansing 
seems  efficient,  but  the  uterus  must  be  removed  if  the  combina- 
tion of  injury  and  infection  makes  its  removal  less  dangerous 
than  its  retention. 

Peritonitis  resulting  from  a  neglected  infected  perforation 
should  be  treated  as  though  it  had  arisen  from  any  other  source, 
there  being  nothing  peculiar  about  it  because  of  its  origin. 

RUPTURE    OF   THE   UTERUS 

Rupture  of  the  uterus  implies  that  force  has  been  used  and  the 
tissues  more  extensively  damaged  than  in  simple  perforation. 

Rupture  of  the  uterus  is  generally  of  obstetric  origin,  but  it 
may  take  place  during  forcible  dilatation  of  the  cervix  of  a  non- 
pregnant uterus.  As  an  obstetric  accident  it  is  of  serious  im- 
port and  is  fully  dealt  with  in  works  devoted  to  that  subject. 
Occurring  during  a  gynaecological  operation  it  may  cause  serious 
hemorrhage,  or,  if  the  case  is  unclean,  dangerous  infection. 
When  rupture  occurs  during  cervical  dilatation,  the  sudden  dis- 
appearance of  resistance  is  unmistakable,  and  the  diagnosis  is 
never  in  doubt. 

Clean  ruptures  into  the  broad  Hgament  are  often  managed 
successfully  by  careful  packing  to  control  the  hemorrhage.  If 
bleeding  persists  in  spite  of  packing,  hsemostasis  is  accompHshed 
by  suture  or  ligature  even  if  necessary  to  split  the  infra-vaginal 
cervix  in  order  to  expose  the  site  of  injury. 

Clean  tears  through  the  peritoneal-covered  surface  of  the 


REFERENCES  28 I 

uterus  extend  into  the  abdominal  cavity  and  they  also  may 
be  treated  by  packing,  but  abdominal  incision  and  suture  of 
the  laceration  gives  greater  security  against  hemorrhage  and 
subsequent  infection. 

If  infection  is  present  in  the  cervix  or  body  of  the  uterus 
and  a  rupture  occurs  which  opens  into  the  abdominal  cavity, 
the  safest  procedure  is  to  open  the  abdomen  and  repair  the 
injury  or  remove  the  uterus  according  to  the  circumstances. 
Drainage  into  the  vagina  should  be  established  unless  the  in- 
fection is  known  to  be  of  so  mild  a  character  that  subsequent 
peritonitis  need  not  be  apprehended. 

REFERENCES 

PESTALOZZA. — Zur  chirurgischen  Behandlung  des  Genitalprolapsus,     Monats. 

f.  Geh.  und  Gyn.,  191 2,  xxvi;  Festschrift  dem,  vi;  Internat.  Gyn.  Kongress,  189. 

MARTIN,  ED. — Der  Genitalprolaps.     Monats.  f.  Geh.  und  Gyn.,  1914,  xxxix,  96. 

HADDEN. — Anatomy  of  the  Female  Pelvis  and  Its  Bearing  on  Procidentia. 

Tr.  Am.  Assn.  Obst.  &'  Gyn.,  1913,  xxvi,  463;  Am.  J.  Obst.,  1914,  Ixix,  316. 
JASCHKE. — Klinisch-anatomische    Beitrage    zur    Aetiologie    des    Genitalpro- 

lapses.     Zeitsch.  f.  Geb.  und  Gyn.,  1913,  Ixxiv,  678. 
MONTGOMERY,    MARTIN,    SOMERS.— Vagino-uterine    Prolapse    and    Its 

Effective  Treatment.     Prolapse  of  the  Uterus.     The  Anatomy  and  Surgical 

Utility  of  the  Sacro-uterine  Ligaments.     J.  A.  M.  A.,  1913,  Ixi,  1245. 
MONTGOMERY,  BALDY,  GOFFE,  POLK,  VINEBERG.— Symposium  on  the 

End  Results  of  Operations  for  Complete  Procidentia  of  the  Uterus.     Trans. 

Am.  Gyn.  Soc,  1912. 
MARTIN. — Uterine  Prolapse.     Surg.,  Gyn.  b°  Obst.,  1907,  iv,  164. 
HIRST. — An  Operation  for  Prolapsus  Uteri,     J.  A.  M.  A.,  191 2,  Iviii,  846. 
POLK. — Suprapubic  Operation  upon  the  Pelvic  Floor  for  Prolapse  of  the  Uterus. 

Am.  J.  Obst.,  1909,  Ix,  418. 
KRONIG. — Bemerkungen  zur  Prolapsoperation.     Arch.  f.  Gyn.,  1910,  xcii. 
KtJSTNER. — Abdominale  Totalextirpation  des  Uterus,  Ventrifixur  des  Scheiden- 

gewolbes,  Kolporrhaphien;  Verfahren  bei    grossen  Prolapsen.     Monats.  f. 

Geb.  und  Gyn.,  19 10,  xxxii,  i. 
WYATT. — ^Lefort's  Operation  for  Prolapse.     /.  Obst.  and  Gyn.  Brit.  Emp.,  191 2, 

xxii,  266. 
DICKINSON  AND  SMITH.— The  Treatment  of  Anteflexion,  Defective  Func- 
tion, and  Sterility  by  Glass  or  Silver  Stems.     Am.  J.  Obst.,  1913,  Ixviii,  686. 
HOLDEN.— The  Treatment  of  Sterility  by  the  Dudley-Reynolds  Operation. 

Am.  J.  Obst.,  1913,  Ixviii,  1064. 


282  DISPLACEMENTS    OF    THE    UTERUS 

WILLIAMS. — The  Causes  of  Backward  Displacement  of  the  Uterus.     Am.  J. 

Med.  Set.,  19 1 5,  cl,  264. 
WILLIAMS. — The  Role  of  the  Pelvic  Fascia  as  a  Uterine  Support.    Am.  J. 

Obst.,  1915,  Ixxi,  575. 
REYNOLDS. — Forward  Fixation  of  the  Cervix  as  a  Predisposing  Cause  of 

Some  Retrodeviations  of  the  Uterus  and  an  Operation  for  Its  Release. 

Surg.,  Gyn.  &'  Obst.,  1914,  xix,  588. 
NOBLE. — Intra-abdominal  Dynamics  and  Mechanical  Principles  Involved  in 

the  Cause  of  Backward  and  Downward  Displacements  of  the  Uterus.     Surg., 

Gyn.  &'  Obst.,  1915,  xx,  45. 
WERDER. — Some  Practical   Considerations  in  the  Treatment  of  Backward 

Displacements  of  the  Uterus.    Penn.  Med.  J.,  191 2,  xv,  437. 
GILES. — Pessaries  Versus  Operations  in  the  Treatment  of  Uterine  Displace- 
ments.    Clin.  J.,  1913,  xlii,  597. 
BISSELL. — A  Contribution  to  the  Study  of  Movable  Retrodisplacements  of  the 

Uterus.     Am.  J.  Obst.,  1915,  Ixxi,  561. 
COFFEY. — The  Principles  on   Which  the  Success  of  Surgical  Treatment  of 

Retrodisplacements  of  the  Uterus  Depends.     Surg.,  Gyn.  b°  Obst.,  1908, 

vii,  383- 
EWALD. — Ueber   die   Endergebnisse   unserer  Opera tionen   wegen    Retroflexio 

Uteri.     Wien.  med.  Woch.,  1913,  Ixiii,  1281. 
CLARK,  KELLY,  HIRST,  CRAGIN,  BOVEE,  GILLIAM,  WEBSTER,  MONT- 
GOMERY, BALDY. — Retroversion  of  the  Uterus.     A  Symposium  on  the 

Operative  Treatment.     Surg.,  Gyn.  &*  Obst.,  1915,  xx,  597. 
VON   HOLST. — Kasuistischer  Beitrag  zur  Inversio  uteri.    Zentralb.  f.  Gyn., 

191 2,  xxxvi,  294. 
KUSTER. — Ueber  Geburt  nach  operative  Antefixation.     Monats.  f.  Geb.  und 

Gyn.,  1 9 14,  xxxix,  168. 
BROWNE. — Inversion  of  the  Uterus.     Trans.  Am.  Gyn.  Soc,  1899,  xxiv,  242. 
HEDLEY. — Two  Cases  of  Complete  Chronic  Inversion  of  the  Uterus  Treated 

by  Abdominal  Section  and  Posterior  Incision  of  the  Uterus.     /.  Obst.  6* 

Gyn.,  Brit.  Emp.,  1915,  xxvii,  8. 
HAULTAIN. — Abdominal  Hysterectomy  for  Chronic  Uterine  Inversion.    Proc. 

Roy.  Soc.  Med.,  1908,  i;  Obst.  b'  Gyn.  Sec,  279. 
SSADEROSKI. — Zur  Kasuistik  der  Uterusperforationen  mit  Darmverletzung. 

Zejilralb.  f.  Gyn.,  1908,  xxxii,  1329. 
WETHERELL. — Accidental   Perforations   of   the   Uterus  and  Vagina.     Surg., 

Gyn.  b'  Obst.,  1909,  ix,  354. 
VON  BRAUN-FERNWALD.— Ueber  Uterusperf oration.     Zentralb.  f.  Gyn.,  1907, 

xxxi,  1161. 
HEYMANN. — Zur  Tnstrumentellen  Perforation  des  nicht  Schwangeren  Uterus. 

Berl.  klin.  Woch.,  1907,  xliv,  1018, 
KUNTSCH. — Uber  instrumentelle  Uterusperforation.     Zentralb.  f.  Gyn.,  1907, 

xxxi,  1590. 
McCANN. — Perforation  of  the  Fundus  Uteri;  Post-abortum.    Proc.  Roy.  Soc. 

Med.,  1913;  Obst.  6*  Gyn.  Sec,  vi,  231. 


CHAPTER  X 

OPERATIONS  UPON  THE  UTERUS  AND  ITS 

LIGAMENTS 

Curettage. — Probably  no  operation  is  so  much  abused  as 
uterine  curettage,  the  sole  direct  result  of  which  is  incomplete 
removal  of  the  mucosa  of  the  body  and  fundus  of  the  uterus. 
It  may  be  performed  for  diagnostic  purposes,  for  hyperplastic 
or  hypertrophic  endometritis  manifesting  itself  by  hemorrhage, 
and  very  rarely  for  chronic  purulent  endometritis  of  non- 
gonorrheal  origin.  Curettage  is  also  justifiable  for  sterility 
if  the  patient  is  perfectly  normal  otherwise.  Curettage  is 
positively  contra-indicated  in  the  presence  of  gonorrheal  in- 
fection of  the  vulva,  vagina,  cervix,  or  tubes. 

The  dangers  of  curettage  are  infection  and  perforation  of 
the  uterus. 

Pre-operative  cleansing  should  be  academic  in  its  thorough- 
ness. The  vulva  should  be  clipped  or  shaven  and  the  external 
genitalia  bathed  the  night  preceding  the  operation.  A  J^-^ 
per  cent,  douche  of  creolin  or  lysol  is  given  on  the  night  pre- 
ceding the  operation  and  repeated  before  the  patient  is  sent 
to  the  surgery.  After  anaesthetization  the  vulva  is  again 
scrubbed  with  soap  and  sterile  water  followed  by  alcohol, 
and  the  vagina  is  washed  out  by  a  nurse  who  wraps  a  piece  of 
gauze  about  the  gloved  fingers  and  proceeds  carefully  and 
systematically  over  every  portion  of  the  vaginal  surface. 
Following  this  another  large  douche  of  1-4000  bichloride  solu- 
tion, i-ioo  lysol  or  creolin,  or  a  prolonged  douche  of  sterile 
water  is  used. 

Sterile  towels  and  sheets  drape  the  legs  and  buttocks,  and 

283 


284     OPERATIONS   tJPON  THE   UTERUS   AND   ITS   LIGAMENTS 

gloves  are  worn  by  all  concerned  precisely  as  for  a  major 
operation. 

Another  bi-manual  examination  is  now  made  to  exclude  tubal 
disease.     When  assured  upon  this  point  the  perineum  is  re- 


FiG.  127. — Curettage.     "The  curette  is  held  lightly  between  the  thumb  and 
first  and  second  fingers,  not  in  the  closed  hand. 

tracted,  the  cervix  seized  with  volsellum  forceps,  and  dilated 
as  previously  described. 

Preliminary  dilatation  is  not  often  required  in  order  to  allow 
the  curette  to  be  introduced,  but  it  renders  the  manipulations 


curettage:  vaginal  fixation  285 

easier  and  assures  the  return  of  the  solutions  which  are  used  for 
irrigation. 

The  curette  with  a  sharp  edge  is  preferred  for  gynaecologic 
curettage  as  the  dull  wire  instrument  will  not  remove  the 
mucosa  without  the  use  of  undue  force,  and  perforation  is 
favored  by  forcible  pressure  applied  to  the  wall  of  the  uterus, 
rather  than  by  scraping  with  a  sharp-edged  loop. 

The  curette  is  held  lightly  between  the  thumb  and  first  and  sec- 
ond fingers,  and  not  in  the  closed  hand.  The  walls  of  the  uterus 
are  scraped  systematically,  giving  especial  attention  to  the 
uterine  horns  and  the  top  of  the  fundus.  The  Recamier  curette 
is  somewhat  superior  to  those  in  common  use  for  removing 
the  mucosa  about  the  tubal  openings  and  along  the  fundus. 

When  the  instrument  impinges  upon  firm  tissue  over  the 
entire  uterine  wall  the  curette  is  laid  aside  and  the  irrigator 
carefully  introduced.  Debris  and  clots  are  thoroughly  washed 
out  with  sterile  water,  care  being  taken  that  the  fluid  escapes 
as  rapidly  as  it  flows  in.  Antiseptic  solutions,  and  swabbing 
or  packing  of  the  uterus  are  generally  unnecessary.  The  vagina 
is  dried,  the  uterus  replaced,  and  a  sterile  dressing  applied  to 
the  vulva. 

The  after-care  is  simple.  The  vulva  is  protected  by  sterile 
dressings  and  douched  after  each  urination  and  defecation. 
No  vaginal  douches  are  used.  The  diet  should  be  restricted 
to  the  necessities  of  a  resting  individual  and  the  bowels  main- 
tained in  normal  condition  by  enemas  or  mild  laxatives.  The 
patient  remains  in  bed  for  four  or  five  days  and  after  a  week 
may  gradually  resume  her  usual  occupation. 

VAGINAL   FIXATION 

Fixation  of  the  uterus  through  the  vagina  is  rarely  indicated, 
prolapse  of  the  uterus  and  vagina  in  a  patient  with  an  extremely 
thick  abdominal  wall,  or  in  one  who  has  a  decided  aversion  to 


286     OPERATIONS   UPON   THE  UTERUS   AND   ITS   LIGAMENTS 

abdominal  incision  affording  the  indication  for  an  occasional 
resort  to  the  operation. 

Like  all  forms  of  uterine  fixation  it  is  positively  contra-indi- 
cated if  there  is  a  possibility  of  future  pregnancy. 

After  the  usual  preparation  the  patient  is  placed  in  the  lith- 
otomy position  and  the  cervix  drawn  through  the  vulva  with 
tenaculum  forceps.     A  transverse  incision  is  made  through  the 


Fig.  128. — Vaginal  fixa- 
tion. Line  of  incision  for 
reflexion  of  vaginal  flaps. 


Fig.  129. — Vaginal  fixation.  "By 
dissecting  up  the  flaps  just  outlined 
the  bladder  is  exposed." 


vaginal  mucosa  at  the  anterior  cervico-vaginal  junction.  A 
longitudinal  incision  through  the  anterior  vaginal  wall  meets 
this  at  a  right  angle,  the  anterior  end  of  the  second  incision  being 
placed  at  the  level  of  the  internal  urethral  orifice.  By  dissecting 
up  the  flaps  thus  outlined  the  bladder  is  exposed  and  carefully 
pushed  away  from  the  vaginal  wall  laterally  for  a  distance 
sufficient  to  allow  the  uterine  fundus  to  be  implanted  between 
them.     The  bladder  is  then  pushed  away  from  the  supra- vaginal 


VAGINAL   FIXATION 


287 


portion  of  the  cervix  by  the  gauze-covered  fingers,  care  being 
taken  that  all  pressure  is  made  against  the  cervix  in  order  to 
guard  against  injury  to  the  bladder.  The  peritoneum  is  ex- 
posed and  torn  through  at  the  vesico-uterine  excavation.  With 
the  fingers  or  forceps  the  uterine  fundus  is  then  grasped,  ante- 
flexed  through  the  peritoneal  opening,  and  tucked  beneath  the 


Fig.  130.  Fig.  131. 

Fig.  130. — Vaginal  fixation.  The  previously  exposed  bladder  has  been 
pushed  away  from  the  cervix,  the  peritoneum  torn  through  and  the  fundus 
anteflexed  through  the  peritoneal  opening. 

Fig.  131. — Vaginal  fixation.  The  uterine  fundus  has  been  sharply  flexed 
forward  and  sutures  to  close  longitudinal  vaginal  incision  include  some  uterine 
tissue. 

bladder  and  between  it  and  the  anterior  vaginal  wall.  In- 
terrupted sutures  close  both  the  longitudinal  and  transverse 
incisions  in  the  anterior  vaginal  wall,  and  one  or  two  of  them 
should  secure  some  uterine  tissue  in  their  grasp. 

The  result  of  this  procedure  is  firm  fixation  of  the  uterus  in 
a  position  of  extreme  anteversion  with  the  bladder  elevated 
above  the  uterine  body. 


2SS     OPERATIONS    UPON  THE   UTERUS   AND   ITS   LIGAMENTS 

VAGINAL   HYSTERECTOMY 

In  the  average  surgical  practice  vaginal  hysterectomy  prob- 
ably is  most  frequently  performed  for  prolapsus  uteri,  in  which, 
according  to  the  author's  views,  it  is  rarely  indicated.  For 
very  early  carcinoma  of  the  uterus,  for  small  fibromata,  and  for 
uterine  hemorrhage  at  or  near  the  menopause  which  persists  in 
spite  of  repeated  curettage,  it  maybe  used  as  a  curative  measure. 


Fig.  132. — Vaginal  fixation.  Vaginal  incisions  closed.  When  cervix  is 
released  from  volsellum  the  uterus  will  straighten  out  with  its  fundus  under 
bladder. 


In  advanced  carcinoma  of  the  cervix  it  is  sometimes  per- 
formed in  order  to  overcome  the  hemorrhage  and  foul  discharge, 
although  it  offers  no  promise  of  cure  of  the  disease  itself. 

For  some  years,  under  the  lead  of  French  and  Belgian  surgeons 
vaginal  hysterectomy  was  extensively  performed  for  pelvic  in- 
flammatory disease,  but  at  the  present  time  more  conservative 
methods  again  prevail. 


VAGINAL  HYSTERECTOMY 


289 


Vaginal  hysterectomy  is  most  easily  performed  when  there  is 
a  small,  freely  movable,  non-adherent  uterus,  a  capacious  vagina 
and  a  relaxed  outlet.  It  becomes  progressively  harder  the 
smaller  the  vagina  and  the  larger  the  uterus,  and  is  very  diffi- 
cult indeed  if  that  organ  is  both  enlarged  and  densely  adherent. 

The  major  dangers  are  hemorrhage,  injury  to  the  bladder, 
ureters,  and  intestine. 

After  the  patient  is  in  the  lithotomy  position  and  the  final 
cleansing  finished,  the  perineum  is  retracted  and  the  cervix 


Fig.  133. — Vaginal   fixation.     Sagittal   section   after   operation  »is   completed. 

drawn  down  as  far  as  possible.  The  cervico-vaginal  junction  is 
demonstrated  by  pushing  the  cervix  within  the  vulva  and  noting 
its  attachment  to  the  vaginal  wall,  and  this  is  now  severed  by  a 
circular  incision  which  extends  completely  around  the  cervix. 
Active  bleeding  is  controlled  by  haemostats  at  this  time.  The 
connective-tissue  attachments,  both  in  front  and  behind,  but 
not  at  the  sides  of  the  cervix,  are  now  pushed  off  with  a  gauze- 
covered  finger  which  makes  pressure  against  the  cervix.     A 

strand  of  dense  tissue  is  present  in  the  mid-line  anteriorly  and 
19 


290     OPERATIONS   UPON  THE  UTERUS   AND   ITS   LIGAMENTS 


Fig.  134.  Fig.  135. 

Fig.  134. — Vaginal  hysterectomy.  Cervico- vaginal  attachment  has  been 
severed  by  a  circular  incision  and  flap  rolled  back;  anterior  view. 

Fig.  135. — Vaginal  hysterectomy.  Cervico-vaginal  junction  has  been  severed 
and  flap  rolled  back.  Clamps  on  bases  of  broad  ligaments ;  posterior  view.  "  It  is 
optional  whether  clamps  be  placed  now  or  later." 


Fig.  [136. — Vaginal  hysterectomy. 
Incision  of  peritoneum  after  strip- 
ping bladder  from  cervix.  Broad  liga- 
ment bases  clamped. 


F^iG.  137. — Vaginal  hysterectomy. 
The  fingers  are  inserted  into  the  open- 
ing between  the  bladder  and  uterus  in 
order  to  anteflex  the  fundus  into  the 
vagina. 


VAGINAL  HYSTERECTOMY  29 1 

usually  requires  snipping  with  a  scissors  whose  points  are  kept 
in  contact  with  the  cervix.  Dry  dissection  with  the  finger  is 
continued  anteriorly  and  posteriorly  until  the  peritoneum  ap- 
pears in  the  depths  of  the  wound.  This  is  recognized  by  its 
thinness  and  the  fact  that  it  moves  independently  of  the  viscera 
above  it.  The  peritoneum  may  be  torn  through  with  the  fingers, 
or  caught  and  cut  as  in  opening  the  abdomen  through  the  an- 
terior wall.  Both  anterior  and  posterior  openings  through  the 
peritoneum  are  torn  laterally  by  the  introduction  of  the  fore- 
fingers of  either  hand,  after  which  the  uterus  is  found  to  be 
suspended  by  the  broad  Ugaments  and  the  structures  between 
their  folds. 

Two  methods  are  available  for  controlling  the  blood  supply 
to  the  uterus  before  proceeding  to  its  removal  by  severing  the 
broad  hgaments. 

A.  By  Clamp. — It  is  optional  with  the  operator  whether  this 
step  shall  be  performed  before  the  peritoneum  is  opened  as 
described  in  the  preceding  section,  but  in  either  case  the  first 
pair  of  clamps  should  not  enter  the  abdominal  cavity.  The 
cervix  is  drawn  strongly  to  one  side  and  the  first  clamp  applied 
to  the  base  of  the  broad  Hgament  on  the  opposite  side  close 
to  the  supra-vaginal  portion  of  the  cervix.  The  same  pro- 
cedure follows  for  the  other  base.  If  difficulty  is  experienced 
in  drawing  down  the  uterus,  that  portion  of  the  broad-ligament 
base  now  embraced  by  clamps  may  be  severed  on  both  sides 
between  the  clamps  and  the  cervix.  With  tenaculum  forceps 
and  fingers  the  uterus  is  now  anteflexed  through  the  anterior 
vaginal  incision.  If  the  tubes  and  ovaries  are  diseased  they  are 
drawn  through  the  opening  at  the  same  time.  A  finger  is 
hooked  over  the  top  of  the  broad  ligament  on  one  side,  the  end 
of  the  finger  touching  the  clamp  already  placed  from  below, 
and  another  clamp  is  then  applied  to  the  broad  ligament  from 
above  downward  so  that  its  tips  contact  with  those  of  the  first 
clamp.     The  broad  ligament  which  is  held  in  the  grip  of  these 


292     OPERATIONS  UPON  THE  UTERUS   AND   ITS   LIGAMENTS 

two  clamps  is  now  cut  from  above  downward  until  the  incision 
meets  the  one  which  was  made  from  below. 

The  uterus  is  now  held  only  by  the  top  of  one  broad  ligament 
and  may  be  swung  entirely  outside  the  vagina  while  this  liga- 
ment is  clamped  from  above  and  the  uterus  cut  away.  If  the 
tube  and  ovary  of  either  side  are  to  be  removed,  the  clamp  which 


Fig.  138. — Vaginal  hysterectomy.  The  base  of  the  right  broad  ligament 
clamped  from  below  upward.  The  top  of  the  right  broad  ligament  clamped 
from  above  downward. 

controls  the  top  of  the  broad  ligament  of  that  side  is  placed 
external  to  the  appendages,  but  if  they  are  to  be  saved  the  clamp 
should  be  between  the  ovary  and  the  uterus. 

If  the  maneuvers  have  been  skillfully  performed  only  these 
four  clamps  are  needed  to  control  the  vessels  in  the  broad 
ligaments.     If  the  clamp  method  is  to  be  used  in  its  entirety, 


VAGINAL  HYSTERECTOMY 


293 


the  haemostats  on  the  vaginal  incision  are  tied  off,  and  the  cavity 
from  which  the  uterus  was  removed  is  lightly  packed  with  iodo- 
form gauze  to  a  point  above  the  tips  of  the  clamps.  The  vagina 
is  now  packed  with  gauze  around  the  shanks  of  the  clamps  in 
such   fashion  as  to  prevent  them  from  coming  into  contact 


Fig.  139. — Vaginal  hysterectomy.     The  right  broad  ligament  severed  and  the 
uterus  swung  out.     The  left  broad  ligament  clamped. 


with  the  vaginal  wall,  and  a  large  sterile  dressing  is  applied  to. 
the  vulva. 

If  hgatures  are  to  supplant  the  broad-ligament  clamps  for 
permanent  haemostasis,  they  are  appHed  after  the  uterus  is 
removed,  and  are  tied  as  close  to  the  clamps  as  possible.  Catgut 
may  be  used  for  this  purpose,  but  a  good-sized  silk  thread  is 
safer,  and  as  the  tissue  which  was  caught  in  the  grasp  of  the 


294     OPERATIONS   UPON  THE  UTERUS  AND   ITS   LIGAMENTS 


forceps  usually  sloughs,  no  sinus  is  to  be  apprehended  from 
retention  of  the  knot.  It  is  especially  important  to  loosen, 
but  not  remove,  each  forcep  as  the  first  knot  is  drawn  down 
behind  it.  Unlocking  the  forcep  assures  compression  of  the 
tissues  by  the  ligature,  and  by  keeping  it  in  position  until  the 
first  knot  is  tied  retraction  and  loss  of  the  stump  are  prevented. 
A  modification  of  this  method  is  necessary  if  for  any  reason 
the  uterus  cannot  be  anteflexed  through  the  anterior  vaginal 

incision,  and  six  or  eight  clamps  may 
be  needed  instead  of  four. 

This  modification  consists  in  first 
clamping  the  broad  ligament  bases 
and  severing  them  from  below  as 
above  described.  The  uterus  thus 
partially  freed  is  drawn  lower  and 
another  pair  of  clamps  applied  on 
the  tissue  lateral  to  the  uterus,  this 
tissue  then  being  cut  between  the 
uterus  and  clamps.  This  clamping 
and  cutting  is  repeated  until  the 
uterus  is  entirely  free,  when  the 
clamps  may  be  left  in  place  or  sup- 
planted by  ligatures  as  desired. 
Greater  care  must  be  used  in  apply- 
ing the  clamps  in  this  manner  lest 
intestine  be  caught,  and  the  uterus 
should  be  closely  hugged  at  each 
succeeding  application  to  guard  against  including  the  ureters. 
B.  Ligature  Method.^ — The  cervico-vaginal  attachment  hav- 
ing been  severed,  the  bladder  dissected  away  anteriorly,  and 
the  peritoneum  opened  both  in  front  and  behind  the  uterus, 
the  broad-ligament  base  on  one  side  is  perforated  by  a  blunt 
needle  carrying  a  heavy  ligature.  This  ligature  is  tied  just 
far  enough  from  the  cervix  so  that  sufficient  stump  is  left  within 
its  grasp  to  prevent  slipping.     The  tissue  between  the  ligature 


Fig.  140. — Vaginal  hysterec- 
tomy. Pryor's  clamps  with 
detachable  handles  have  been 
left  for  permanent  haemostasis. 
Gauze  covers  the  tips  and 
shanks  of  the  clamps. 


VAGINAL  HYSTERECTOMY 


295 


and  cervix  is  severed,  and  the  process  of  tying  and  cutting 
repeated,  first  upon  one  side  and  then  on  the  other,  until  the 
uterus  is  freed. 

When  any  ligature  method  has  been  used,  the  round  liga- 
ments and  a  portion  of  the  broad  Hgaments  may  be  sewn 
together  across  the  cavity  from  which  the  uterus  has  been 


FiCt,  141, — Vaginal  hysterectomy.  Method  used  when  uterine  fundus  cannot 
be  brought  through  wound.  The  broad  ligaments  are  clamped  and  cut  piece- 
meal from  below  upward. 

removed,  thus  surrounding  the  opening  and  at  the  same  time 
assisting  to  maintain  the  integrity  at  the  vaginal  vault.  Some 
space  should  be  left  for  drainage,-  however,  as  vaginal  hysterec- 
tomy cannot  be  performed  in  an  absolutely  aseptic  manner  and 
the  great  safety  of  this  operation  probably  is  due  to  free  drainage 
through  the  vagina. 


296     OPERATIONS    UPON   THE   UTERUS   AND   ITS    LIGAMENTS 

After-care.— If  clamps  are  left  the  patient  should  be  catheter- 
ized  until  they  are  removed,  and  care  be  taken  not  to  loosen  them 
accidentally  during  catheterization.  Pryor's  clamps  with  re- 
movable handles  are  an  effectual  safeguard  against  this  accident, 
and  they  also  minimize  the  patient's  discomfort  during  the  first 
few  days. 

The  clamps  are  removed  in  from  48  to  72  hours,  each  clamp 
being  unlocked  and  allowed  to  remain  in  position  for  a  few 
moments  in  order  to  be  sure  that  hemorrhage  will  not  occur. 
It  is  then  slowly  and  gently  withdrawn.  The  gauze  in  the 
pelvic  cavity  is  left  until  it  is  thoroughly  loosened  which  usually 
requires  seven  or  eight  days,  but  the  vaginal  gauze  may  be 
changed  once  or  twice  during  this  time  if  it  becomes  offensive. 
Iodoform  gauze  remains  sweet  much  longer  than  plain  gauze 
and  thus  needs  less  frequent  changing.  Douches  are  not  neces- 
sary until  all  the  gauze  is  permanently  removed,  and  even  then 
they  should  be  given  without  pressure  so  that  fluid  is  not 
forced  into  the  pelvic  cavity. 

The  bowels  should  not  be  moved  until  the  clamps  are  off,  and 
should  then  receive  the  same  attention  as  in  any  operation  in- 
volving the  peritoneal  cavity.  The  patient  should  remain  in 
bed  until  union  is  firm,  usually  about  two  weeks. 

Special  Points  in  Technique. — i.  The  operation  is  easier  if 
the  peritoneum  is  opened  before  clamping  and  cutting  the  broad- 
ligament  bases,  but  this  is  not  imperative  and  under  some 
circumstahces  is  impossible. 

2.  Injury  to  the  bladder  can  be  avoided  only  if  the  dissection 
anterior  to  the  uterus  is  made  close  against  the  cervix. 

3.  The  risk  of  clamping  or  tying  the  ureters  is  minimized  by 
pushing  the  bladder  away  from  the  broad  ligament  at  either 
side  of  the  cervix,  and  hugging  the  uterus  closely  with  clamps 
and  ligatures. 

4.  Hemorrhage  must  positively  be  controlled  either  by  clamps 
or  ligatures  before  the  operation  is  completed. 


INGUINAL   SHORTENING    OF    THE   UTERINE   LIGAMENTS       297 
INGUINAL    SHORTENING    OF    THE    UTERINE    LIGAMENTS 

Shortening  the  round  hgaments  through  the  inguinal  canals 
is  a  recognized  method  of  treating  movable  retroversion  and 
retroflexion,  and  its  indications  are  discussed  sufficiently  under 
displacements. 

All  operations  of  this  type  are  based  upon  the  original  Alex- 
ander operation,  and  while  numerous  modifications  have  been 
presented  from  time  to  time,  any  method  is  satisfactory  by  which 


Fig.  142.  Fig.  143. 

Fig.  142. — Inguinal  shortening  of  the  round  ligaments.     Line  of  incisions. 
Fig.  143. — Inguinal  shortening  of  the  round  ligaments.     The  right  round  liga- 
ment has  been  isolated  from  the  fatty  tissue  in  the  inguinal  canal. 

the  ligaments  are  demonstrated!  in  the  inguinal  canals,  drawn 
out  until  the  uterine  fundus  meets  the  anterior  abdominal  wall, 
and  folded  upon  themselves  or  otherwise  shortened  in  such 
manner  as  to  retain  the  uterus  in  that  position. 

An  incision  through  the  skin  and  subcutaneous  fat  extending 
from  the  level  of  the  abdominal  inguinal  ring  to  the  pubic  bone, 
and  paralleHng  the  inguinal  ligament,  exposes  the  fatty  tissue 
in  the  subcutaneous  ring.     This  fatty  tissue  is  teased  apart  with 


298     OPERATIONS    UPON   THE   UTERUS   AND   ITS    LIGAMENTS 


forceps  or  picked  up  on  blunt  hooks  until  definite  muscular  fibers 
appear.  It  should  be  remembered  that  the  ligaments  fray  out 
rapidly  as  they  approach  the  mons  pubis  and  are  thicker  to- 
ward the  abdominal  ring.  So  soon  as  these  muscle  fibers  are 
found  they  should  be  traced  upward  and  freed  from  fat  until 
the  outhne  of  the  ligament  is  plainly  visible,  when  the  ligament 
is  completely  isolated  to  its  exit  from  the  abdominal  cavity. 
Gentle  traction  causes  the  Hgament  to  "run"  through  the 
inguinal  canal  and  abdominal  ring. 

Both  ligaments  having 
been  demonstrated  and 
cleared,  they  may  be  short- 
ened by  folding  them  upon 
themselves  and  stitching  the 
folds  together,  greater  secur- 
ity being  obtained  by  in- 
serting one  or  two  sutures 
through  the  ligament  and 
one  of  the  pillars  of  the  sub- 
cutaneous ring.  Gersuny 
makes  a  tunnel  under  the 
skin  and  superficial  fascia  be- 
tween the  inferior  ends  of  the 
two  incisions,  and  fixes  the  Hgaments  in  this  tunnel  with  sutures. 
Difficulty  is  sometimes  experienced  in  picking  up  the  hga- 
ment in  the  subcutaneous  ring,  either  because  it  is  much  thinned 
out  or  absent.  In  this  event  a  stab  wound  may  be  made 
through  the  abdominal  muscles  over  the  abdominal  ring  and  the 
ligaments  picked  up  with  blunt  hooks  at  this  level,  brought 
through  the  muscle  incision,  and  stitched  to  the  external  surface 
of  the  external  oblique  aponeurosis. 

Separation  of  the  pillars  of  the  ring,  or  any  incision  in  the 
muscles  covering  the  inguinal  canal,  should  be  carefully  repaired 
or  a  hernia  may  result.  Should  peritoneum  appear  when  the 
ligaments  are  drawn  out,  it  is  to  be  wiped  upward  to  avoid  the 


Fig.  144. — Inguinal  shortening  of  the 
round  ligaments.  The  right  round  liga- 
ment has  been  drawn  out  and  a  stitch  in- 
serted through  the  doubled  ligament  and 
internal  pillar. 


THE   ALEXANDER   OPERATION 


299 


formation  of  a  peritoneal  pouch  which  is  the  first  step  in  the 
evolution  of  a  post-operative  inguinal  hernia.  Haemostasis 
should  be  absolute  and  asepsis  pedantic,  as  suppuration  is  in- 


FiG.  145. — Inguinal  shortening  of  the  round  ligaments.     Both  ligaments  have 
been  stitched  to  the  external  oblique  aponeurosis. 

duced  more  readily  in  this  locality  than  in  any  other  portion  of 
the  abdominal  wall. 

The  after-treatment  is  that  of  a  simple  laparotomy,  but 
especial  care  is  necessary  that  the  bladder  does  not  become  dis- 
tended and  force   the   uterus   posteriorly   before   healing  is 


300     OPERATIONS    UPON   THE    UTERUS    AND   ITS    LIGAMENTS 

complete.  A  pessary  may  be  introduced  at  the  close  of  the 
operation  and  allowed  to  remain  for  several  weeks  to  assist  in 
retaining  the  uterus  in  its  normal  position  if  a  plastic  operation 
has  not  been  performed  at  the  same  sitting. 


Fig.  146. — Intra-abdominal  shortening  of  the  round  ligaments.  The  Gilliam 
operation.  The  round  ligaments  are  surrounded  by  loops  of  silk  to  act  as 
tractors.     Diagrammatic.     (Redrawn  from  Gilliam.) 


INTRA-ABDOMINAL  SHORTENING  OF  THE  UTERINE  LIGAMENTS 

Various  methods  have  been  devised  for  shortening  the  round 
ligaments  after  opening  the  abdomen,  but  the  two  most 
generally  useful  are  the  Gilliam  and  the  Baldy-Webster. 


THE  BALDY- WEBSTER   OPERATION 


301 


The  salient  points  of  the  Gilliam  are  as  follows:  After  the 
abdomen  is  opened  in  the  mid-line  the  anterior  sheaths  of  the 
recti  are  cleared  of  fat  and  a  perforation  is  made  on  either  side, 
2  cm.  external  to  the  margin  of  the  incision.  This  perforation 
is  4  cm.  above  the  crest  of  the  pubes  and  extends  through  all 
the  layers  of  the  abdominal  wall  beneath  the  superficial  fascia 


^ 

V 

Ijlll 

^Kr     fmm          ^m     ^S 

v^ 

^ 

^^^^UHHs^      ^k^^^^K^^^T    Wt''^'^^^^ 

AX 

Fig.  147. — Intra-abdominal  shortening  of  the  round  ligaments.  The  Gilliam 
operation.  A  perforation  has  been  made  through  the  right  rectus  fascia  and 
muscle  through  which  the  ligament  is  to  be  drawn.     {Redrawn  from  Gilliam.) 

and  fat.  One  round  Hgament  is  surrounded  by  a  loop  of  silk 
4  cm.  from  its  uterine  attachment,  and  with  a  blunt  instrument 
this  loop  is  drawn  through  the  above-mentioned  perforation 
pulling  the  ligament  with  it.  This  procedure  is  repeated  on  the 
other  side,  and  the  operation  is  finished  by  stitching  each  loop 
of  round  ligament  to  the  margin  of  the  perforation  through  the 
rectus  fascia. 


302     OPERATIONS    UPON   THE   UTERUS   AND   ITS    LIGAMENTS 

The  advantages  of  the  Gilliam  operation  are  that  it  does  not 
interfere  with  future  labor  and  that  it  suspends  the  uterus  by 
the  stronger  inner  ends  of  the  ligaments.  Its  disadvantages 
are  the  formation  of  two  bands  in  the  abdominal  cavity,  and 
the  possibility  that  one  or  both  ligaments  may  give  way  because 
of  pressure  atrophy  of  that  portion  which  extends  through  the 
abdominal  muscle  and  fascia. 


^ 

M 

^      y 

'^^ 

J^^/^<^WM 

w 

^Mm 

j^^^ 

^1 

^^C 

f^^/^ 

^^^^ 

'^^ 

Fig.  148. — Intra-abdominal  shortening  of  the  round  ligaments.  The  Gilliam 
operation.  Loops  of  both  round  ligaments  are  ready  to  stitch  to  anterior 
sheath  of  rectus.     {Redrawn  frojn  Gilliam.) 

The  method  of  shortening  the  round  ligaments  known  as 
the  Baldy-Webster  operation  is  applicable  to  the  same  class 
of  cases  as  the  Gilliam.  By  it  the  uterus  is  brought  forward 
into  a  normal  position,  but  instead  of  its  being  suspended  from 
the  anterior  abdominal  wall  the  ligaments  themselves  are 
shortened  and  given  a  new  point  of  attachment  to  the  uterus. 
In  order  to  accomplish  this  the  uterine  tube  is  raised  and  a 
hajmostat  thrust  from  behind  forward  through  the  clear  space 
just  external  to  the  lateral  uterine  wall.     The  round  ligament 


THE  BALDY- WEBSTER   OPERATION 


303 


is  caught  in  the  jaws  of  the  haemostat  and  drawn  back  through 
the  perforation  in  the  broad  Kgament.  This  is  repeated  on  the 
other  side  and  sufhcient  traction  made  upon  the  Hgaments  to 
render  them  taut  up  to  their  entrance  into  the  abdominal  wall. 
The  requisite  degree  of  tension  being  ascertained,  the  ligaments 
being  folded  upon  themselves  are  stitched  to  the  posterior  wall 


Fig.  149. — Intra-abdominal  shortening  of  the  round  Hgaments.  The  "Baldy- 
Webster"  operation.  ''The  uterine  tube  is  raised  and  a  haemostat  thrust  from 
behind  forward  through  the  clear  space."  If  the  ovary  is  prolapsed  this  perfora- 
tion should  be  below  the  ovarian  ligament. 


of  the  uterus.  If  they  are  sufficiently  long,  the  folded  ligaments 
may  also  be  sutured  to  each  other.  The  new  attachment  of 
the  ligaments  to  the  posterior  uterine  wall  should  not  be  more 
than  3  cm.  below  the  fundus.  If  they  are  attached  lower  than 
this  there  is  danger  that  the  uterus  may  somersault  over  them, 
and  thus  make  the  displacement  worse  than  before.  After 
the  ligaments  have  been  sutured  to  the  posterior  uterine  wall, 


304    OPERATIONS   UPON  THE  UTERUS   AND   ITS   LIGAMENTS 

each  one  should  be  stitched  to  the  margin  of  the  opening  in  the 
broad  ligament  through  which  it  passes  in  order  that  no  op- 
portunity may  be  afforded  for  prolapse  of  a  knuckle  of  intestine 
and  possible  strangulation.  A  small  triangular  space  may  be 
found  just  external  to  the  lateral  wall  of  the  uterus,  both  above 
and  below  the  round  hgament,  and  this  should  be  closed  for  the 
same  reason. 


.".m 

»^ 

1 

V- 

vp 

.< ' 

3# 

^ 

/^C. 

Fig.  150. — Intra-abdominal  shortening  of  the  round  ligaments.  ^  The  "Baldy- 
Webster"  operation.  One  ligament  has  been  sewn  to  the  posterior  wall  of  the 
uterus  just  below  the  fundus.     The  second  ligament  is  ready  for  suturing. 


A  modification  of  this  operation  consists  in  stitching  the 
posterior  layers  of  the  broad  Hgaments  to  the  posterior  surface 
of  the  uterus  simultaneously  with  the  attachment  of  the  round 
ligaments  thereto,  and  by  still  another  modification  the  liga- 
ments are  drawn  through  a  tunnel  between  the  peritoneal  and 
muscular  coats  of  the  posterior  uterine  wall  in  order  to  avoid 
the  formation  of  adhesions. 


THE  BALDY- WEBSTER   OPERATION 


305 


While  other  methods  of  intra-abdominal  shortening  of  the 
round  ligaments  are  possible,  such  as  folding  them  in  front  of  the 
uterus,  or  folding  them  upon  themselves  during  their  course 
through  the  broad  ligament,  none  of  them  present  the  ad- 
vantages of  the  above-described  posterior  method.  The  only 
disadvantage  of  the  operation  has  been  mentioned  before,  and 


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^1 

[j^y" 

Fig.  151. — Intra-abdominal  shortening  of  the  round  ligaments.  The  "Baldy- 
Webster"  operation.  Both  ligaments  have  been  stitched  to  the  posterior  uterine 
wall.  The  ligaments'^have  been  stitched  to  the  margins  of  the  openings  in  the 
broad  ligaments  to  obviate  possible  intestinal  strangulation. 


Hes  in  the  fact  that  the  outer  weaker  extremities  of  the  ligaments 
support  the  weight  of  the  uterus.  This  is  probably  more  than 
compensated  by  the  fact  that  the  round  ligaments  now  have 
their  uterine  attachments  on  the  posterior  surface  of  the  uterine 
body,  whereas  they  are  normally  attached  a  trifle  anterior  to 
the  mid-line.  The  forward  pull  upon  the  uterus  which  is 
secured  by  this  operation  has  a  mechanical  advantage  that  is 


20 


3o6     OPERATIONS   UPON  THE  UTERUS   AND   ITS   LIGAMENTS 

not  gained  by  any  other  operation  so  far  devised,  in  that  it 
throws  the  uterus  so  far  anteriorly  as  to  permit  intra-abdominal 
pressure  to  act  on  the  posterior  face  of  the  uterus,  and  so  assist 
in  maintaining  it  in  its  normal  position.  If  an  ovary  is  pro- 
lapsed, the  perforation  through  which  the  round  ligament  is 
drawn  should  be  made  beneath  the  utero-ovarian  ligament 
instead  of  between  it  and  the  tube. 

VENTRO-SUSPENSION 

The  popular  ventro-suspension  operation  which  was  devised 
by  Howard  Kelly  has  a  hmited  field  of  usefulness  and  has 


Fig.  152.  Fig.  153. 

Fig.  152. — Ventro-suspension  of  the  uterus.  Two  stitches  are  inserted.^  A 
silk  stitch  "catches  the  peritoneum  on  one  side  of  the  incision  then  bites  into 
the  posterior  surface  of  the  uterus  just  below  the  fundus  and  passes  out  through 
the  peritoneum  on  the  other  side." 

Fig.  153. — Ventro-suspension  of  the  uterus.  "Both  stitches  are  inserted 
before  either  is  tied."  The  catgut  stitch  embracing  muscle  and  fascia  has  been 
tied. 


been  overdone  because  of  its  simplicity  and  the  ease  with 
which  it  is  performed.     The  abdomen  having  been  opened 


VENTRO-FDCATION  307 

and  any  other  necessary  work  accomplished,  two  or  three 
stitches  are  inserted  at  the  lowermost  angle  of  the  median 
abdominal  incision  as  follows:  One  stitch  of  silk  first  picks 
up  the  peritoneum  on  one  side  of  the  incision,  then  bites 
into  the  posterior  surface  of  the  uterus  just  below  the  fundus, 
and  passes  out  through  the  peritoneum  on  the  other  side. 
The  next  stitch  of  catgut  may  include  the  muscle  and  fascia 
as  well  as  the  peritoneum,  and  both  are  inserted  before  either 
is  tied,  the  tying  not  being  done  until  it  is  certain  that  no  loop 
of  intestine  has  insinuated  itself  betv/een  the  uterine  fundus  and 
the  abdominal  wall.  The  immediate  result  of  the  operation  is 
a  delicate  layer  of  adhesions  between  the  posterior  surface  of 
the  fundus  and  the  anterior  parietal  peritoneum.  After  a  time 
these  adhesions  are  dragged  out  into  a  thin  filamentous  band, 
which  allows  considerable  freedom  of  movement  of  the  uterus, 
but  does  not  permit  its  complete  backward  displacement. 
The  operation  is  contra-indicated  during  the  child-bearing 
period  as  the  fundus  may  be  held  so  far  anteriorly  that  it  cannot 
rise  with  the  growth  of  the  uterus  during  pregnancy.  Should 
this  occur  the  cervix  is  thrown  posteriorly  and  upward,  even 
to  or  above  the  sacral  promontory,  and  enlargement  of  the 
uterus  proceeds  by  a  thinning  out  and  distension  of  its  posterior 
wall  rather  than  by  uniform  growth  in  all  directions. 

VENTRO-FIXATION 

In  distinction  from  the  preceding  operations,  ventro-fixation 
aims  at  producing  firm  adhesions  which  will  not  draw  out  and 
form  a  third  ligament,  and  it  is  used  only  in  extreme  forms  of 
prolapse.  Since  the  operation  is  usually  preceded  by  extensive 
plastic  work  at  the  same  sitting,  the  simplest  effectual  method 
for  its  performance  should  be  chosen.  When  performed  by 
itself,  the  requisite  plastic  procedures  having  been  carried  out 
at  some  previous  time,  one  of  the  more  radical  operations 


3o8    OPERATIONS   UPON  THE  UTERUS   AND   ITS   LIGAMENTS 

may  be  used,  such  as  Crile's  fish  tail  removal  of  the  fundus  and 
body. 

The  ordinary  operation  differs  from  suspension  in  that  the 
uterus  is  drawn  sufficiently  well  into  the  lower  angle  of  the  ab- 
dominal wound  to  permit  suturing  the  parietal  peritoneum  at 
the  margins  of  the  incision  to  the  uterine  fundus  at  some  dis- 


FiG.  154. — Ventro-fixation  of  the  uterus.  "The  parietal  peritoneum  is  su- 
tured to  the  fundus  at  some  distance  from  its  middle."  The  fundus  projects 
between  the  recti  muscles. 


tance  from  its  middle.  The  superior  mid-portion  of  the  fundus 
thus  projects  into  the  abdominal  incision  between  the  recti 
muscles,  and  is  included  in  the  stitches  which  unite  these  muscles 
when  the  abdominal  incision  is  closed.  A  uterus  so  fixed  re- 
mains with  its  fundus  permanently  incorporated  in  the  ab- 
dominal wall,  but  unless  the  pelvic  diaphragm  has  been  effi- 
ciently repaired  the  uterus  may  stretch  out  to  a  great  length 
by  reason  of  the  constant  traction  exerted  upon  it  by  the  pro- 


VAGINAL  MYOMECTOMY  309 

lapsed  bladder,  and  in  this  event  the  cervix  again  will  make  its 
appearance  at  the  vulva. 

MYOMECTOMY 

Vaginal  Myomectomy. — The  removal  of  a  small  cervical 
fibroid  is  easily  accomplished  by  an  incision  carried  to  its  capsule 
through'  the  mucous  and  muscular  tissue  overlying  it.  The 
tumor  is  then  grasped  with  a  volsellum  forceps  and  peeled  out 
of  its  bed  by  blunt  dissection,  and  the  cavity  closed  with  buried 
stitches. 

The  removal  of  an  intra-uterine  myoma  through  the  vagina 
is  simple  if  the  tumor  is  small  and  pedunculated,  or  if  it  has  been 
sufficiently  dehvered  by  Nature's  efforts  to  have  dilated  the 
cervix. 

Large,  sessile  intra-uterine  tumors  were  more  frequently  re- 
moved by  this  method  in  the  past  than  at  present,  when  the 
possibility  of  malignancy  and  the  occurrence  of  multiple  tumors 
are  better  understood. 

Tumors  which  have  been  partially  expelled  from  the  cervix 
are  likely  to  be  infected  or  necrotic,  and  are  better  removed 
through  the  vagina  than  through  an  abdominal  incision. 

With  the  patient  in  the  lithotomy  position  the  final  cleansing 
is  carried  out  and  the  vagina  dilated  to  its  fullest  extent.  The 
cervix  is  grasped  with  the  volsellum  forceps  and  the  relations 
of  the  tumor  ascertained.  Very  small  pedunculated  tumors 
may  be  twisted  off  without  ado.  If  the  cervix  is  sufficiently 
dilated  to  permit  a  larger  tumor  to  be  delivered  intact,  it  is 
grasped  with  large  volsellum  forceps,  drawn  down,  and  an 
incision  made  through  the  mucosa  covering  it.  This  incision 
should  encircle  the  growth  above  its  greatest  circumference,  but 
should  not  be  made  through  a  narrow  pedicle.  Traction  upon 
the  tumor  is  continued  while  the  mucosa  is  pushed  away  from 
the  capsule  in  all  directions  above  the  incision,  and  eventually  it 


3IO    OPERATIONS   UPON   THE   UTERUS   AND   ITS   LIGAMENTS 

is  peeled  entirely  from  its  bed.  If  the  proper  line  of  cleavage 
is  found  between  the  fibrous  capsule  of  the  tumor  and  the  sur- 
rounding tissue  this  dissection  is  easily  accomplished.  The 
hemorrhage  is  surprisingly  slight  and  is  controlled  by  hot  irri- 
gation and  packing  the  bed  of  the  tumor  with  iodoform  gauze. 


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Fig.  155.— -Vaginal  myomectomy.  The  tumor  is  drawn  down  with  volsella 
and  an  incision  is  made  through  the  mucosa  covering  it.  This  incision  encircles 
the  tumor  superior  to  its  greatest  circumference. 

The  removal  of  a  tumor  whose  greatest  circumference  has  not 
escaped  from  the  cervix  necessitates  either  a  reduction  in  the 
size  of  the  growth  or  a  wider  opening  in  the  cervix. 

The  tumor  can  be  reduced  by  the  successive  removal  of 


VAGINAL  MYOMECTOMY 


311 


wedge-shaped  pieces  from  its  inferior  surface.  When  it  is 
sufficiently  small  to  be  delivered  through  the  cervix,  it  is 
removed  in  the  manner  just  described. 


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Fig.  156. — Vaginal  myomectomy.     "Traction  upon  the  tumor  is  continued  while 
the  mucosa  is  pushed  away  from  the  capsule  in  all  directions." 


The  cervix  can  be  enlarged  by  dilatation  or  incision.  Dila- 
tation should  be  practised  in  the  case  of  small  growths  only, 
while  larger  ones  demand  anterior  and  posterior  section  of  the 


312     OPERATIONS   UPON  THE   UTERUS   AND   ITS  LIGAMENTS 

cervix.  This  is  performed  by  making  a  transverse  incision  at 
the  junction  of  the  cervix  and  vagina  anteriorly  and  stripping 
the  bladder  from  the  supra-vaginal  portion  of  the  cervix.  The 
anterior  lip  is  then  grasped  by  two  volsella  forceps,  one  on 
either  side  of  its  mid-line,  and  cut  longitudinally  between  them. 
Due  caution  should  be  exercised  that  the  peritoneum  is  not 
opened  in  the  depths  of  the  wound.  The  posterior  lip  is  split 
in  the  same  manner,  but  preliminary  incision  of  the  cervico- 
vaginal  junction  may  not  be  necessary.  The  tumor  is  now 
removed  and  the  cervical  incisions  sutured  if  the  uterus  is  not 
infected,  or  packed  if  it  is.  If  the  patient  is  in  a  very  serious 
condition  from  hemorrhage,  nephritis,  or  cardio-vascular  dis- 
ease, it  may  be  necessary  to  control  hemorrhage  and  stimulate 
further  dilatation  of  the  cervix  and  expulsion  of  the  tumor 
by  repeated  packing  and  the  hypodermic  use  of  ergot  or  pitu- 
itary extract. 

The  packing  should  be  carried  out  carefully  and  aseptically, 
and  ergot  is  preferable  to  the  pituitary  extracts  for  prolonged 
use.  Once  the  largest  circumference  of  the  tumor  is  forced 
outside  the  cervix  it  can  be  removed  by  the  operation  described 
without  anaesthesia  if  the  general  condition  is  too  serious  to 
justify  the  latter. 

Removal  by  the  snare  or  ecraseur  is  not  advised  as  the  uterus 
may  be  partially  inverted  by  the  dragging  upon  it  of  the  growth, 
and  the  uterine  wall  may  then  be  damaged  or  even  perforated. 
It  is  for  this  reason  also  that  incision  of  the  mucosa  surrounding 
the  tumor  is  made  below  the  pedicle,  instead  of  through  it,  when 
the  tumor  is  to  be  removed  by  blunt  dissection. 

ABDOMINAL   MYOMECTOMY 

Abdominal  myomectomy  has  a  rather  circumscribed  field  of 
usefulness  and  is  applicable  only  to  a  limited  class  of  cases  for 
the  same  reasons  that  apply  to  the  vaginal  operation.  Even 
when  a  fibroid  of  considerable  size  seems  to  be  solitary,  other 


ABDOMINAL   MYOMECTOMY  313 

very  minute  ones  may  be  found  in  the  uterine  wall,  and  if  only 
the  large  growth  is  removed  these  small  seedlings  may  continue 
to  grow  and  necessitate  another  operation  later. 

Abdominal  myomectomy  also  has  a  slightly  higher  mortality 
rate  than  supra-vaginal  hysterectomy.  It  is  useful,  however, 
in  young  women  in  whom  the  function  of  child-bearing  should 
not  be  interfered  with  if  the  tumors  are  moderate  in  size  and 


Fig.  157. — Abdominal  myomectomy.  The  uterine  wall  is  incised  longitu- 
dinally, the  incision  penetrating  into  the  tumor  in  order  to  demonstrate  to  a 
certainty  the  plane  of  the  tumor  capsule. 

limited  in  number,  or  if  they  are  distinctly  pedunculated.  If 
the  tumor  is  pedunculated  its  pedicle  may  be  excised  close  up 
against  the  uterine  wall,  the  bleeding  controlled  by  deep  catgut 
sutures,  and  neighboring  peritoneum  drawn  over  the  raw  area 
by  means  of  Lembert  sutures.  If  the  tumor  is  sessile  or  in- 
terstitial, the   wall  of   the   uterus  over   the  most  prominent 


314    OPERATIONS   UPON  THE   UTERUS   AND   ITS   LIGAMENTS 

portion  of  the  tumor  should  be  incised  in  the  longitudinal  axis 
of  the  uterus  until  the  tumor  is  reached.  Berkley  and  Bonney 
advise  that  in  making  this  incision  the  knife  penetrate  a  short 
distance  into  the  tumor,  the  object  being  to  give  one  an  idea 
as  to  the  exact  location  of  its  true  capsule.  When  the  capsule 
is  demonstrated  the  overlying  uterine  wall  may  be  separated 
from  it  by  blunt  dissection,  bleeding  being  controlled  by  up- 
ward traction  upon  the  uterus,  or  if  hemorrhage  is  excessive, 
by  having  an  assistant  control  the  ovarian  and  uterine  arteries 
by  grasping  the  broad  ligaments  with  the  hands.  The  tumor 
shells  out  with  little  difficulty  if  the  line  of  cleavage  between 
the  capsule  and  uterine  wall  is  accurately  ascertained.  The 
cavity  left  after  extirpation  of  the  tumor  should  be  closed  by 
deep  catgut  sutures  which  encircle  all  bleeding  points.  If  the 
tumor  is  more  than  a  mere  knob  on  the  surface  of  the  uterus, 
several  layers  of  sutures  will  be  needed  to  completely  occlude 
this  cavity,  after  which  the  peritoneum  is  drawn  over  the  inci- 
sion by  means  of  Lembert  stitches.  All  vessels  should  be  con- 
trolled and  dead  spaces  completely  obliterated,  but  excessively 
tight  sutures  must  be  avoided  or  sloughing  may  be  induced  and 
a  perforation  take  place  between  the  uterine  and  abdominal 
cavities.  Great  mutilation  of  the  uterine  wall  by  the  removal 
from  it  of  a  large  number  of  sessile  growths  is  not  justifiable 
in  consideration  of  the  smooth  convalescence  and  low  mortality 
rate  of  supra-vaginal  hysterectomy. 

HYSTERECTOMY 

Supra-vaginal  Hysterectomy. — The  sub-total  hysterectomy 
of  EngHsh  writers  is  an  operation  of  distinctly  modern  develop- 
ment, and  so  far  as  technique  is  concerned  it  would  seem  as  if 
perfection  had  been  reached.  Variations  from  the  typical 
operation  are  required  when  growths  expand  the  broad  liga- 
ment, large  tumors  develop  within  the  cervical  canal,  or  arise 
in  the  wall  of  the  ceivix  and  project  under  the  bladder  an- 


SUPRA-VAGINAL  HYSTERECTOMY  315 

teriorly  or  under  the  peritoneum  posteriorly.  Very  dense  adhe- 
sions also  may  render  the  typical  operation  more  dangerous 
than  one  of  its  modifications. 

In  ordinary  instances  of  hysterectomy  for  fibroids,  for  tubo- 
ovarian  disease  with  marked  uterine  infection,  and  for  intract- 
able hemorrhage,  as  well  as  in  hysterectomy  following  Cesarean 
section,  the  typical  operation  leaves  nothing  to  be  desired  in  the 
way  of  trivial  post-operative  discomfort,  smooth  convalescence, 
and  ultimate  recovery.  The  abdomen  is  opened  by  an  incision 
sufficiently  large  to  allow  thorough  exposure  of  the  field  of 
operation,  and  any  visible  adhesions  are  separated  so  that  the 
uterus  and  tumor  may  be  drawn  out  of  the  abdominal  cavity. 
Dense  adhesions  which  lie  deep  in  the  pelvic  cavity  under  the 
tumor  should  not  be  separated  until  they  can  be  seen,  as  injury 
to  veins  in  this  locality  may  result  in  severe  hemorrhage  which 
cannot  be  controlled  until  the  uterus  is  removed.  If  the  patient 
is  very  stout  or  the  uterus  small,  it  may  be  impossible  to  draw 
it  through  the  abdominal  incision,  and  in  this  event  it  is  pulled 
up  as  far  as  possible  with  volsellum  forceps  and  drawn  from  side 
to  side  until  the  landmarks  can  be  ascertained.  These  land- 
marks are  the  tops  of  the  broad  ligaments  and  the  round 
ligaments  lateral  to  the  uterus,  the  sacro-uterine  ligaments 
posteriorly,  and  the  utero-vesical  ligaments  anteriorly.  The  first 
step  in  the  actual  removal  of  the  uterus  is  to  apply  clamps  to  the 
top  of  each  broad  ligament.  These  clamps  are  intended  to 
control  the  ovarian  vessels,  and  the  exact  site  for  their  applica- 
tion depends  upon  whether  or  no  the  ovaries  and  tubes  are  to  be 
removed  with  the  uterus.  If  they  are,  the  clamps  should  be 
apphed  between  the  ovary  and  the  pelvic  wall  and  should  ex- 
tend down  a  sufficient  distance  to  control  both  the  ovarian 
artery  and  ovarian  veins.  Another  clamp  should  be  placed  on 
each  broad  ligament  well  in  toward  the  lateral  wall  of  the  uterus 
so  as  to  prevent  regurgitation  of  blood  from  the  tumor  when  the 
broad  Ugaments  are  cut.  The  round  ligament  may  be  included 
in  the  first  clamp  unless  the  top  of  the  broad  ligament  is  very 


3l6     OPERATIONS   UPON  THE   UTERUS   AND   ITS   LIGAMENTS 

much  expanded  by  the  growth,  in  which  event  a  separate  clamp 
must  be  used^for  this  purpose.  Having  secured  the  ovarian 
vessels  and  the  vessels  of  the  round  hgament,  the  top  of  the 
broad  ligament  is  cut  on  each  side  far  enough  from  the  clamp 
which  controls  the  ovarian  vessels  to  obviate  retraction  of  the 
stump.  The  round  ligament  on  each  side  is  now  cut  on  the 
median  side  of  its  clamp,  hemorrhage  from  the  artery  in  its 


/fsa^^ud 


Fig.  158. — Supra-vaginal  hysterectomy.  Anterior  view.  Top  of  right  broad 
ligament  clamped  and  cut  between.  Top  of  left  broad  ligament  and  round 
ligament  clamped  and  cut  between  clamps. 

uterine  end  being  controlled  by  the  clamp  on  the  broad  ligament 
at  the  lateral  wall  of  the  uterus. 

Separation  of  the  vesico-uterine  fold  of  peritoneum  is  next  in 
order.  This  may  be  done  by  first  cutting  a  peritoneal  flap  with 
the  knife,  or  better  by  inserting  a  fmger  under  the  anterior 
layer  of  broad  ligament  where  this  has  been  severed  as  just 


SXJPRA-VAGINAL  HYSTERECTOMY 


317 


described.  Pushing  the  finger  or  a  blunt  dissector  under  this 
fold  of  peritoneum  lifts  it  from  its  attachments  to  the  supra- 
vaginal cervix  approximately  one-half  across  its  anterior  face. 
Repetition  of  this  maneuver  upon  the  other  side  frees  the  peri- 
toneum at  the  utero-vesical  junction,  and  the  scissors  may  then 
be  used  to  cut  the  peritoneal  flap  making  it  of  any  length  which 
the  exigencies  of  the  case  demand.     Having  turned  this  flap 


/iSCh^^Ui 


Fig.  159. — Supra-vaginal  hysterectomy.  Cutting  peritoneum  at  utero-vesical 
junction.  Finger  or  blunt  dissector  first  raises  flap  which  is  then  cut  with 
scissors. 

downward,  the  bladder  is  pushed  off  from  the  anterior  cervical 
wall  with  a  gauze  covered  finger,  the  blunt  dissection  extending 
well  out  at  either  side  in  order  to  crowd  the  ureters  farther  away 
from  the  cervix.  The  tops  of  the  broad  ligaments,  the  round 
ligaments,  and  the  anterior  peritoneal  flap  having  been  cut,  the 
uterus  may  now  be  drawn  much  farther  out  of  the  abdominal 
cavity.     A  moment's  search  will  usually  reveal  the  uterine 


3l8    OPERATIONS   UPON  THE   UTERUS  AND   ITS   LIGAMENTS 

vessels  immediately  adjacent  to  the  antero-lateral  wall  of  the 
supra- vaginal  cervix.  It  will  be  remembered  that  each  uterine 
artery  runs  inward  through  the  base  of  the  broad  Hgament, 
crosses  the  ureter,  and  then  turns  up  along  the  lateral  uterine 
wall.  The  proper  location  for  the  clamps  to  be  so  placed  upon 
the  artery  as  not  to  endanger  the  ureter  is  easily  ascertained. 
When  the  clamps  are  appHed  at  right  angles  to  the  uterus  with 


Fig.  i6o. — Supra-vaginal  hysterectomy.  The  bladder  has  been  pushed  down 
from  the  supra-vaginal  cervix  by  blunt  dissection.  The  uterine  arteries  are 
clamped  after  they  turn  upward  along  the  cervix. 

the  points  grasping  the  vessel  superior  to  its  upward  turn,  in- 
jury to  the  ureter  is  impossible.  The  posterior  layers  of  the 
broad  ligaments  are  now  snipped  with  scissors  down  to  the 
level  of  the  clamps  upon  the  uterine  vessels,  when  the  body  of 
the  uterus  will  be  found  to  have  lost  all  its  attachments  except- 
ing that  to  the  cervix.  Regurgitation  from  the  uterine  end  of 
any  vessels  should  be  controlled  by  clamping,  for  while  such 


SUPRA-VAGINAL  HYSTERECTOMY 


319 


blood  is  already  lost  to  the  patient  it  obscures  the  field  and 
endangers  the  safety  and  neatness  of  the  operation. 

The  cervix  is  now  cut  across  with  knife  or  scissors  in  such 
manner  as  to  leave  a  V-  or  cup-shaped  depression  in  its  center. 
Traction  upon  the  uterine  body  while  the  cervix  is  being  severed 
assists  materially  in  producing  this  depression  which  makes 
suturing  of  the  stump  much  easier.     Bleeding  vessels  upon  the 


Fig.  161. — Supra-vaginal  liysterectomy.  The  cervix  has  been  partially 
severed  from  before  backward.  Ligatures  are  shown  on  the  uterine  vessels. 
Ordinarily  these  are  placed  and  tied  after  the  cervix  is  completely  severed. 

anterior  or  posterior  walls  of  the  cervix,  or  any  branches  of  the 
uterine  which  may  have  escaped  the  clamps  are  caught  as  they 
are  divided.  When  the  cervix  has  been  cut  partially  across,  its 
stump  is  caught  with  a  volsellum  in  order  that  it  may  not  drop 
out  of  sight  when  completely  detached.  The  cervical  canal  is 
then  closed  by  a  single  mattress  stitch  and  three  or  four  ad- 


320     OPERATIONS   UPON  THE   UTERUS   AND   ITS   LIGAMENTS 

ditional  interrupted  stitches  close  the  remainder  of  the  stump. 
Interrupted  sutures  are  preferred  to  continuous  as  they  offer 
less  opportunity  for  pressure  necrosis  and  possible  gangrene  of 
the  stump.  Any  vessels  which  may  have  been  picked  up  in  the 
stump  should  be  included  in  these  stitches,  and  if  one  or  two 
strings  are  left  long  they  may  be  used  to  manipulate  the  stump 
when  the  volsellum  is  removed.  The  tissue  in  the  clamps  which 
control  the  ovarian  vessels  should  now  be  tied.     As  the  first 


Fig.  162. — Supra-vaginal  hysterectomy.  A  mattress  stitch  has  been  placed 
to  close  the  cervical  canal.  Interrupted  stitches  in  place  to  close  the  cervical 
flaps.  Clamps  on  ovarian  vessels  and  tubes,  round  ligaments,  and  uterine 
arteries  have  been  supplanted  by  ligatures. 

turn  of  the  knot  is  being  drawn  taut  the  clamp  is  loosened,  but 
not  entirely  removed  until  it  is  definitely  ascertained  that  the 
ligature  will  not  break.  The  uterine  arteries  are  best  tied  with 
a  suture  ligature  which  bites  into  the  cervical  wall  immediately 
below  the  point  of  the  clamp.  If  the  ureters  are  known  to  be 
safe,  silk  or  chromic  catgut  may  be  used  on  the  uterine  arteries, 
but  if  for  any  reason  the  exact  location  of  the  ureters  is  unknown 
plain  catgut  had  best  be  used  and  reinforced  by  a  tie  upon  the 


SUPRA-VAGINAL  HYSTERECTOMY 


321 


uterine  artery  as  it  projects  from  the  mass  of  tissue  included  in 
the  ligature.  The  stump  of  the  round  ligament  is  now  tied 
unless  it  already  has  been  included.  If  there  is  any  question 
concerning  the  security  of  the  ligature  upon  any  one  of  the  four 
cardinal  vessels  it  should  be  re-tied  at  once,  and  no  chance  be 
taken  that  oozing  may  stop  or  a  ligature  may  hold.  When 
hemostasis  is  assured  the  entire  raw  surface  is  covered  over  as 


Fig.  163. — Supra-vaginal  hysterectomy.     The  cervical  stump  has  been  closed. 
A  continuous  stitch  covers  over  all  raw  surfaces. 


follows:  With  a  small  needle  and  fine  catgut  a  suture  is  started- 
just  external  to  the  stump  of  one  ovarian  artery  which  whips  to- 
gether the  peritoneum  forming  the  anterior  and  posterior  folds 
of  the  broad  hgament,  inverting  any  raw  areas  as  they  appear. 
When  this  suture  has  arrived  at  the  lateral  wall  of  the  uterus 
the  flap  of  peritoneum  attached  to  the  bladder  is  sewn  to  the 
posterior  peritoneal-covered  surface  of  the  cervix  by  a  series  of 
Lembert  stitches,  and  from  the  opposite  lateral  wall  the  suture 
is  then  continued  on  the  opposite  broad  ligament  until  it  ends 
beyond  the  Hgature  upon  the  ovarian  stump  of  that  side.     All 


21 


322     OPERATIONS    UPON   THE   UTERUS   AND    ITS    LIGAMENTS 

raw  areas,  including  the  cervical  stump,  are  thus  covered  by  peri- 
toneum, and  if  the  work  has  been  done  neatly  the  bottom  of  the 
pelvic  cavity  presents  a  dry,  smooth  appearance  with  no  de- 
nuded surface.  Any  blood  is  now  removed  from  the  bottom  of 
the  pelvic  basin  or  pubo-vescial  excavation  by  means  of  a  sponge 
wet  in  saline  solution,  the  surfaces  are  gently  dried,  and  the 
abdomen  closed  without  drainage. 

Special  Points  in  Technique. — i.  A  moderate  Trendelen- 
burg position  is  of  assistance  during  the  separation  of  such  ad- 
hesions as  need  the  aid  of  sight  as  well  as  touch.  The  extreme 
Trendelenburg  position  is  rarely  required  and  should  not  be  used 
unless  necessary. 

2.  In  separating  adhesions  care  must  be  taken  that  they  are 
stripped  from  the  structures  to  be  removed  rather  than  from  the 
viscera. 

3.  One  should  be  very  circumspect  while  separating  adhesions 
which  are  hidden  underneath  a  tumor.  The  veins  in  this 
locality  are  large  and  any  injury  done  to  them  in  the  depths  of 
the  pelvis  cannot  be  corrected  until  the  tumor  is  out  of  the  way. 

4.  Time  consumed  in  placing  pads  and  sponges  in  such  a 
manner  as  to  thoroughly  wall  off  the  entire  abdominal  cavity 
above  the  pelvic  structures  is  time  well  spent,  as  it  keeps  the 
field  free  from  intestine,  avoids  soiHng,  and  prevents  shock. 

5.  If  a  clamp  sHps  from  a  primary  vessel,  or  if  that  vessel  has 
not  been  included  in  the  clamp  designed  to  hold  it,  the  operator 
should  not  grasp  at  it  blindly  as  by  so  doing  the  gut,  the  bladder, 
or  the  ureter  may  be  seriously  damaged.  The  few  ounces  of 
blood  which  may  be  lost  in  the  moment  or  two  required  to  ac- 
curately locate  the  bleeding  vessel  is  of  slight  importance  com- 
pared to  damaged  viscera  or  a  clamped  ureter. 

6.  At  that  stage  of  the  operation  in  which  the  cervical  canal 
is  cut  across,  its  uterine  end  should  be  covered  with  a  gauze 
sponge  to  prevent  the  possible  entrance  of  material  from  the 
body  of  the  uterus.  While  this  ordinarily  is  sterile,  breaking 
down  polypi  or  even  beginning  carcinoma  may  be  present  and 


SUPRA-VAGINAL  HYSTERECTOMY  323 

the  discharge  from  these  may  contain  virulent  micro-organisms. 
It  does  no  harm,  and  may  be  judicious,  to  steriHze  the  exposed 
mucosa  in  the  cervical  stump  by  the  application  of  pure  carbolic 
acid,  any  excess  being  neutralized  with  alcohol. 

OPERATIVE   MODIPICATIONS    FOR    UNUSU^^L    CONDITIONS 

As  before  mentioned,  certain  cases  present  themselves  in  which 
the  foregoing  technique  for  supra-vaginal  amputation  of  the 


Fig.  164. — Supra-vaginal  hysterectomy  from  side  to  side.  The  uterine  vessels 
on  the  diseased  side  are  caught  by  a  clamp  "which  crosses  the  stump  of  the  cer- 
vix transversely." 

uterus  is  impracticable.  A  tumor  which  originates  low  in  the 
cervix  and  grows  between  the  layers  of  the  broad  ligament  may 
elevate  the  ureter  over  it,  and  if  in  such  a  case  the  ordinary 
technique  were  followed,  injury  to   the  ureter  could  not  be 


324     OPERATIONS    UPON   THE   UTERUS   AND   ITS   LIGAMENTS 

avoided.  When  it  is  found  that  a  fibroid  which  grows  from  the 
lateral  wall  of  the  uterus  is  contained  between  the  anterior  and 
posterior  folds  of  the  broad  ligament,  the  operation  should  pro- 
ceed as  before  up  to  the  point  where  only  the  uterine  arteries 
remain  to  be  controlled;  that  is,  the  ovarian  vessels  may  be 
clamped  on  both  sides,  the  round  ligaments  clamped  or  tied, 


Fig.   165. — Supra-vaginal    hysterectomy    for    fibroid    growing    into   left  broad 
ligament.     Side-to-side  amputation  of  uterus. 

and  the  anterior  flap  of  peritoneum  cut.  The  broad  ligament 
on  the  side  opposite  the  tumor  is  then  severed  to  the  level  of  the 
uterine  artery,  the  uterine  vessels  on  the  same  side  caught,  and 
the  uterus  amputated  from  the  cervix  before  securing  the  uter- 
ine vessels  on  the  side  which  contains  the  tumor.  As  the  cervix 
is  cut  across  the  vessels  in  the  stump  should  be  secured  and  the 
tumor  rolled  out  by  traction  upon  the  uterus,  when  the  uterine 


SUPRA-VAGINAL  HYSTERECTOMY 


325 


Fig.  166. — Supra-vaginal  hysterectomy  from  side  to  side.  Uterus  removed, 
stitch  for  occlusion  of  cervical  canal  is  placed.  The  cervix  is  to  be  closed  from 
side  to  side. 


Fig.  167. — Supra-vaginal  hysterectomy  from  side  to  side.     Cervix  closed, 
areas  in  process  of  closing  as  in  usual  operation. 


Raw 


326     OPERATIONS   UPON   THE   UTERUS    AND    ITS    LIGAMENTS 

artery  on  the  diseased  side  will  be  exposed  and  should  be  caught 
by  a  clamp  which  crosses  the  stump  of  the  cervix  transversely 
and  grasps  the  vessel  as  the  final  stroke  of  the  knife  severs  the  last 


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Fig.  168. — Supra-vaginal  hysterectomy  for  libroid  expanding  the  cervix. 
The  tops  of  the  broad  ligaments  have  been  clamped  and  cut.  A  short  cut  is 
made  in  "the  anterior  cervical  wall  through  which  a  line  of  cleavage  is  found 
between  the  muscular  tissue  of  the  cervix  and  the  capsule  of  the  tumor." 

bit  of  muscular  tissue.  The  tumor  can  now  be  drawn  from  its 
bed  in  the  broad  ligament  by  working  from  below  upward,  and 
if  the  ureter  has  not  been  displaced  by  the  tumor  it  will  not  be 


SUPRA-VAGINAL   HYSTERECTOMY 


327 


seen.    If  it  has  been  displaced,  it  will  be  observed  and  brushed  off 

into  the  connective  tissue  of  the  broad  hgament  without  injury. 

When  a  large  growth  projects  from  the  cervix  underneath  the 

bladder  it  can  be  attacked  as  recommended  by  Murphy.     The 


Fig.  169. — Supra-vaginal  hysterectomy  for  fibroid  expanding  the  cervix.     The 
finger  is  separating  the  tumor  from  its  envelope  of  cervical  muscle. 

tops  of  the  broad  ligaments  and  the  round  ligaments  are  secured 
and  cut  as  before,  and  the  cervico-uterine  junction  is  then 
severed  from  behind  forward,  cutting  only  in  the  muscular  tissue 
of  the  cervix.  Traction  is  made  upon  the  uterus  and  the  uterine 
vessels  are  exposed  at  either  side  of  the  cervix  and  are  there 


328     OPERATIONS   UPON   THE   UTERUS   AND   ITS   LIGAMENTS 

clamped  and  cut.  By  drawing  the  uterus  and  tumor  over  the 
pubes  they  can  be  rolled  out  of  their  connective  tissue  bed 
until  the  bladder  wall  is  reached,  when  this  is  gradually  peeled 
from  the  tumor  by  blunt  dissection,  the  final  step  being  the 
fashioning  of  the  anterior  peritoneal  flap  from  below. 


Fig.  170. — Supra-vaginal  hysterectomy  for  fibroid  expanding  the  cervix. 
The  tumor  has  been  loosened  by  blunt  dissection.  The  anterior  cervical  wall 
has  been  cut  transversely  and  small  vessels  caught. 


Tumors  which  grow  into  the  interior  of  the  cervix,  expanding 
its  wall  around  them  and  attaining  a  great  size,  present  very 
serious   difiiculties.     In   their   removal   the   operation   should 


SUPRA-VAGINAL  HYSTERECTOMY 


329 


proceed  in  the  typical  fashion  through  the  stages  of  clamping 
and  cutting  the  tops  of  the  broad  and  round  ligaments.  After 
these  prehminary  steps  have  been  taken,  the  bladder  beneath 
the  anterior  peritoneal  flap  is  pushed  down  to  the  top  of  the 


Fig,  171. — Supra- vaginal  hysterectomy  for  fibroid  expanding  the  cervix. 
The  tumor  is  being  rolled  from  its  bed.  The  uterine  arteries  are  clamped  from 
within  outward . 

vagina.  No  attempt  to  control  the  uterine  vessels  on  either 
side  is  made  at  this  stage  since  the  immediate  proximity  of 
the  ureters  makes  their  injury  almost  certain.  Owing  to  the 
expansion  of  the  cervix  by  the  growth  of  the  tumor  in  its  in- 


330    OPERATIONS    UPON   THE   UTERUS    AND   ITS    LIGAMENTS 

terior,  the  cervical  wall  forms  a  thin  muscular  capsule  external 
to  the  true  tumor  capsule,  and  the  tumor  itself  should  be  enu- 
cleated from  this  muscular  capsule  before  any  attempt  is  made 
at  removal  of  the  uterus.     This  is  accomplished  by  making 


Fig.  172. — Supra-vaginal  hysterectomy  for  fibroid  expanding  the  cervix. 
The  tumor  has  been  removed  and  the  uterine  vessels  tied.  Sutures  laid  to  close 
the  cervical  canal  and  tumor  bed. 

a  short  cut  in  the  anterior  cervical  wall  through  which  a  line 
of  cleavage  is  found  between  the  muscular  tissue  of  the  cervix 
and  the  capsule  of  the  tumor.  The  finger  is  then  inserted 
through  this  incision  and  the  entire  growth  separated  from  the 
interior  of  the  cervix  by  blunt  dissection  along  the  line  of 


PAN-HYSTERECTOMY  33 1 

cleavage.  The  incision  in  the  anterior  cervical  wall  is  then 
enlarged,  the  tumor  withdrawn  from  the  interior  of  the  cavity, 
and  the  uterine  vessels  caught  at  the  sides  of  the  now  collapsed 
cervix.  If  bleeding  from  the  cavity  is  free  and  the  main  vessels 
are  not  readily  located,  the  entire  uterus  may  be  amputated 
at  the  level  of  the  original  cut,  clamping  the  small  arteries  in 
the  stump  as  they  spurt,  when  the  primary  vessels  at  the  sides 
of  the  cervix  can  be  secured  without  difficulty.  The  clamps 
which  catch  the  uterine  vessels  should  be  directed  from  within 
outward  across  the  stump,  rather  than  from  without  inward, 
in  order  to  avoid  the  ureters  which  are  in  close  proximity  to 
the  cervix  and  antero-lateral  walls  of  the  vagina. 

PAN-HYSTERECTOMY 

Pan-hysterectomy  may  be  performed  when  a  severe  lacera- 
tion of  the  cervix  co-exists  with  any  condition  demanding 
removal  of  the  body  of  the  uterus.  It  is  the  operation  of  choice 
for  carcinoma  of  the  body  and  fundus,  and  is  sometimes  per- 
formed for  very  early  cervical  carcinoma.  Because  of  the 
frequent  association  of  mahgnancy  with  fibroids  of  the  uterus, 
some  authors  advise  pan-hysterectomy  instead  of  supra- vaginal 
amputation  in  all  cases  of  the  latter  disease.  Inasmuch  as  the 
mortality  rate  for  pan-hysterectomy  is  at  least  double  that  for 
supra-vaginal  amputation,  the  latter  advice  seerris  somewhat 
too  radical. 

The  technique  of  complete  hysterectomy  is  rendered  less 
difficult  by  severing  the  cervico-vaginal  junction  through  the 
vagina  before  the  abdominal  portion  of  the  operation  is  begun. 
The  advantage  gained  in  this  way  is  not  sufficient  to  justify  its 
adoption  as  a  routine  measure,  but  if  a  cystocele  or  relaxed 
vaginal  outlet  needs  correction  it  may  be  well  to  precede 
the  required  plastic  work  by  this  incision.  In  case  the  opera- 
tion is  performed  entirely  from  above  the  technique  is  the  same 
as  for  supra-vaginal  amputation  up  to  the  point  of  severing 


332     OPERATIONS    UPON   THE    UTERUS    AND   ITS    LIGAMENTS 

the  body  of  the  uterus  from  the  cervix.  A  very  simple  method 
of  completing  the  operation  consists  in  amputating  the  uterus 
and  then  dissecting  the  cervical  stump  from  its  attachments 
to  the  broad  ligaments  and  vagina.  Usually,  however,  it  is 
better  to  proceed  without  separate  removal  of  the  body  of  the 


Fig.  173. — Pan-hysterectomy.  Anterior  view.  The  tops  of  the  broad  liga- 
ments clamped  and  cut.  The  bladder  is  stripped  from  the  cervix  and  upper 
portion  of  the  vagina. 

uterus,  and  strip  the  bladder  from  the  entire  anterior  cervical 
wall  and  upper  portion  of  the  vagina.  The  uterus  is  drawn 
well  forward  over  the  pubes  and  the  sacro-uterine  Hgamcnts 
noted.  These  ligaments  and  the  peritoneum  between  them 
are  severed  transversely,  and  the  connective  tissue  separating 


PAN-HYSTERECTOMY 


333 


the  peritoneum  from  the  posterior  vaginal  wall  is  picked  up  and 
cut  across,  the  incision  extending  into  the  vagina  if  this  has  not 
been  done  from  below.  Two  fingers  are  now  introduced  into 
the  vagina  through  this  opening,  passed  anteriorly  beneath  the 
cervix,  and  made  to  impinge  upon  the  anterior  vaginal  wall 
between  the  bladder  and  the  cervix,  when  a  transverse  incision 


Fig.   174. — Pan-hysterectomy.     Posterior  view.     Transverse   incision  through 
recto-uterine    excavation,    the    incision    extending    into    the    vagina. 

through  this  wall  can  be  made  without  endangering  the  bladder. 
The  uterus  is  now  suspended  solely  by  its  lateral  attachments 
to  the  bases  of  the  broad  ligaments,  and  it  is  entirely  freed  when 
these  lateral  strips  of  tissue  are  clamped  with  narrow-bladed 
forceps  and  cut  between  the  forceps  and  cervix. 


334    OPERATIONS    UPON   THE    UTERUS    AND    ITS    LIGAMENTS 

It  is  understood  that  vessels  in  the  severed  vaginal  wall  are 
caught  as  they  bleed. 

Permanent  hemostasis  is  now  effected  by  ligatures  placed 
upon  all  the  clamped  tissue,  those  which  secure  the  broad  liga- 
ments being  placed  close  to  the  clamps  in  order  to  avoid  the 


Fig.  175. — Pan-hysterectomy.  Anterior  view.  Two  fingers  have  been  passed 
through  the  posterior  incision  just  shown.  The  tips  of  the  fingers  are  pushing 
against  the  anterior  vaginal  wall  to  show  point  for  anterior  incision. 


ureters.  The  lumen  of  the  opening  into  the  vagina  may  be 
narrowed  by  suturing  each  lateral  angle,  but  the  vagina  should 
not  be  entirely  closed  as  a  mild  grade  of  infection  of  the  opened 
connective-tissue  spaces  is  fairly  frequent.     Drainage  of  these 


PAN-HYSTERECTOMY 


335 


areas  may  be  secured  by  a  cigarette  drain  or  gauze  wick  which 
projects  into  the  vagina  through  the  opening  in  its  vault. 

The  peritoneum  covering  the  bottom  of  the  pelvic  cavity  is 
then  sutured  as  in  supra-vaginal  amputation,  excepting  that 


Fig.  176. — Pan-hysterectomy.  Anterior  view.  "The  uterus  is  suspended 
solely  by  its  lateral  attachments  to  the  bases  of  the  broad  ligaments."  "These 
strips  of  tissue  are  clamped  with  narrow-bladed  forceps." 

the  peritoneal  flap  depending  from  the  posterior  wall  of  the 
bladder  is  sutured  to  that  made  by  incising  the  recto-uterine 
excavation.     The  abdomen  is  closed  without  drainage  in  the 


336     OPERATIONS   UPON   THE   UTERUS   AND    ITS    LIGAMENTS 

absence  of  sepsis  or  malignant  disease,  and  if  drainage  is  re- 
quired it  should  be  effected  through  the  vaginal  vault  rather 
than  the  abdominal  incision. 

While  many  other  methods  of  removing  the  entire  uterus 
have  been  practised,  the  two  above  described  fulfill  all  the  in- 
dications for  pan-hysterectomy  for  benign  disease. 

PAN-HYSTERECTOMY   FOR    CARCINOMA    OF    THE    CERVIX 

The  profession  is  largely  indebted  to  Wertheim  of  Vienna 
and  Ries  of  Chicago  for  the  inauguration  of  an  amplified 
method  for  removing  the  entire  uterus  for  malignant  disease 
of  the  cervix,  and  no  description  of  the  operation  excels  that 
given  by  Wertheim  in  Surgery,  Gynaecology  and  Obstetrics  for 
January,  1907. 

The  following  important  principles  should  be  emphasized: 

1.  To  go  as  wide  of  the  diseased  cervix  as  possible  in  those 
structures  where  extension  is  first  to  be  apprehended.  These 
structures  are  the  parametrium  and  the  vaginal  wall. 

2.  To  consider  the  carcinomatous  cervix  as  inevitably  and 
dangerously  infected  and  so  to  handle  it  as  to  minimize  the 
danger  both  from  implantation  metastases  and  peritonitis. 

To  these  some  would  add  a  third — to  remove  the  regional 
lymphatics — but  aside  from  its  academic  interest  this  does  not 
seem  to  be  of  any  practical  importance  as  lymphatic  involve- 
ment usually  means  early  recurrence. 

The  salient  points  in  the  operation  are  as  follows:  Im- 
mediately preceding  the  abdominal  operation  the  cervix  should 
be  thoroughly  cauterized.  It  is  sometimes  advised  that  this 
be  done  a  few  days  before  the  chief  operation,  but  the  sloughs 
and  granulating  surface  left  after  this  lapse  of  time  must  be 
more  dangerous  from  the  standpoint  of  infection  than  the 
cervix  thoroughly  cauterized  immediately  before  opening  the 
abdomen.     The  vagina  should  be  mopped  out  with  full-strength 


PAN-HYSTERECTOMY  FOR  CARCINOMA 


337 


tincture  of  iodine  at  the  close  of  the  vaginal  portion  of  the 
operation. 


Fig.  177. — Pan-hysterectomy.  {Wertheim.)  "  By  dividing  the  posterior  layer 
of  the  broad  ligament  the  ureters  are  exposed  up  to  their  entrance  into  the  para- 
metrium." 

Gloves,  instruments,  drapes,  and  gowns  all  should  be  care- 
fully changed  before  the  abdominal  operation  is  begun. 

The  patient  is  elevated  into  the  Trendelenburg  position  before 
22 


338     OPERATIONS    UPON   THE    UTERUS   AND   ITS    LIGAMENTS 

the  abdomen  is  opened,  and  as  soon  as  the  incision  is  made  the 
intestine  is  packed  away  above  the  pelvic  brim.  This  packing 
should  be  done  most  carefully  so  that  nothing  remains  in  the 


n||L              ^    I'rfi'iiE^ 

1^ 

^     ^^1 

fflHSwK^^ 

^^^ 

'^'             '^mm 

i^^H^ 

■r 

■R^^^^^i  |k^^^^^^B|^p^ 

^^^K    \ 

Fig.   178. — Pan-hyslcrcctomy.     (Wrrl/ieini.)     "After    dividing  the  peritoneum 
the  bladder  must  be  separated  from  the  uterus." 

pelvic  cavity  but  the  fixed  viscera.  The  suitabihty  of  the  case 
for  radical  operation  is  next  determined,  as  it  is  impossible 
to  be  certain  before  the  abdomen  is  opened  whether  radical 


PAN-HYSTERECTOMY  FOR  CARCINOMA  339 

extirpation  offers  a  sufficient  hope  of  permanent  cure  to  justify 
the  risk.  The  earlier  the  case  the  more  justification  for  an  ex- 
tensive operation. 


Fig.  179. — Pan-hysterectomy,     (Wertheim.)     "Then    follow    the    ligation  and 
division  of  the  infundibulo-pelvic  ligament." 

If  the  bladder  and  rectum  are  not  involved  and  the  para- 
metrium and  ureters  are  free  from  palpable  disease,  the  case 
is  suitable  for  the  most  widespread  dissection. 


340    OPERATIONS   UPON  THE   UTERUS   AND   ITS   LIGAMENTS 

The  upper  portions  of  the  broad  ligaments  are  clamped  and 
cut  well  out  toward  the  pelvic  wall.  The  anterior  flap  of  peri- 
toneum is  cut,  and  the  bladder  bluntly  dissected  from  the  cervix 


Fig.  i8o. — Pan-hysterectomy.     (Wertheim.)    "  The  broad  and  round  ligaments." 

and  upper  one-third  of  the  anterior  vaginal  wall.  The  uterus 
is  drawn  forward  and  the  ureters  are  demonstrated  and  un- 
covered, but  not  dissected  from  their  bed.  This  may  be  ac- 
complished by  longitudinally  incising  the  peritoneum  at  the 


PAN-HYSTERECTOMY  EOR  CARCINOMA 


341 


bifurcation  of  the  common  iliac  arteries  on  either  side.  On 
raising  the  peritoneum  the  ureter  will  be  found  adherent  to  its 
posterior  surface  just  to  one  or  the  other  side  of  the  incision 


■^..^^^te     ^^ 

ilM-' 

^><; 

r 

^^ 

1 

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^ 

^ 

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Fig.  181. — Pan-hysterectomy.  (Wertheim.)  "The  index  finger  of  one  hand 
is  pushed  along  the  ureter  through  the  parametrium.  The  vessels  are  then 
raised  on  the  finger." 

which  is  now  extended  over  the  course  of  the  ureter  to  the 
point  at  which  it  is  crossed  by  the  uterine  artery,  and  that 


342     OPERATIONS   UPON   THE    UTERUS    AND    ITS    LIGAMENTS 

vessel  together  with  the  broad-ligament  base  is  clamped 
external  to  the  ureter.  Both  arteries  being  controlled,  the 
broad-ligament  bases  are  cut  downward  and  inward  toward  the 


Fig.  182.— Pan-hysterectomy.     {Wcrllicim.)     "  So  that  the  ligation  and  division 
of  the  vessels  can  take  place  without  injury  to  the  ureter." 

lateral  vaginal  walls,  and  the  sacro-uterine  ligaments  are 
treated  in  the  same  manner.  The  peritoneum  of  the  recto- 
uterine excavation  is  cut  transversely,  and  the  rectum  and  vagina 


PAN-HYSTERECTOMY   FOR   CARCINOMA 


343 


separated  downward  for  at  least  3  cm.  The  uterus  is  now  held 
by  its  vaginal  attachment  only  and  the  vagina  is  clamped  with 
right-angled   clamps,   one  pair  immediately  below  the  other. 


Fig.  183. — Pan-hysterectomy.     (Wertheim.)     "In  simple  cases  the  vesical  end 
of  the  ureter  separates  without  diflSculty." 

The  incision  which  is  to  free  the  uterus  and  upper  portion  of 
the  vagina  is  made  between  these  clamps,  the  upper  pair  pre- 
venting infection  of  the  peritoneum  from  the  cervix,  the  lower 


344    OPERATIONS   UPON  THE   UTERUS   AND  ITS   LIGAMENTS 

pair  preventing  infection  from  the  vagina  and  temporarily 
controlling  hemorrhage  from  its  cut  edges. 

The  ureters  should  be  in  plain  view  during  all  the  maneuvers 
which  follow  the:?preliminary  step  of  clamping  and  cutting  the 


Fig.  184. — Pan-hysterectomy.     (Wertheim.)     "Next  follows  the  separation  of 

the  rectum  from  the  vagina." 

round  ligaments  and  tops  of  the  broad  ligaments.     Hemorrhage 
from  the  vaginal  wall  is  permanently  controlled  by  clamping  and 


PAN-HYSTERECTOMY  FOR  CARCINOMA 


345 


tying  as  the  preliminary  right-angled  clamp  is  loosened,  and  the 
lateral  angles  of  the  vagina  are  then  sewn  up.  Bleeding  from 
the  vaginal  plexus  of  veins  is  likely  to  be  free  and  should  be 


Fig.  185. — Pan-hysterectomy.    (Wertheim.)  "  For  this  purpose  the  parametrium 
is  divided  as  closely  as  possible  to  the  pelvic  wall." 


controlled  by  ligatures  and  suture  ligatures.  The  central  por- 
tion of  the  vagina  is  left  open  for  drainage  of  the  connective- 
tissue  spaces  as  in  pan-hysterectomy  for  benign  conditions,  and 
the  peritoneum  closed  over  the  raw  surfaces  as  in  that  operation. 


346     OPERATIONS   UPON   THE   UTERUS    AND   ITS    LIGAMENTS 

Should  a  break  in  the  technique  permit  the  least  soiling  by  any 
material  from  the  cancerous  cervix,  the  peritoneum  should  be 
closed  at  its  lateral  aspects  only,  and  the  whole  bottom  of  the 


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Hp 

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1 

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Jf 

w 

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F 

j[ 

^^^S^^Sflf^'^^^^^M 

l^y  M  'i'i^^K^^^^E^K^Kr  ^KBL 

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Jf 

Fig.  1 86. — Pan-hysterectomy.  {Werlheim.)  The  previous  step  should  be 
l)rccccled  by  "applying  to  the  parametrium  before  dividing  it,  four  or  five  bent 
clamps." 


pelvic  cavity  be  drained  by  a  loose  mass  of  gauze  extending  into 
the  vagina.     The  abdomen  is  closed  as  usual. 

This  brief  description  while  differing  in  minor  points  gives  an 


PAN-HYSTERECTOMY  FOR  CARCINOMA 


347 


idea  of  the  extent  and  thoroughness  of  the  radical  operation  as 
advocated  by  Wertheim. 


1^^ 

1 

^^1^83 

^'"^x^^^^ 

%^ 

^^^^^ 

^^^m        m                i  \                    mm- 

■  i^U^^I 

Fig.  187. — Pan-hysterectomy.     {Wertheim.)     "Strong  clamps  are    applied    to 
the  vagina  before  its  division  so  as  to  isolate  the  cancer  from  the  vagina." 


To  the  author  the  combined  operation  appeals  more  strongly 
than  this  operation  which  is  entirely  abdominal. 


348     OPERATIONS   UPON  THE   UTERUS   AND   ITS   LIGAMENTS 

COMBINED  VAGINAL  AND  ABDOMINAL  OPERATION  FOR  CARCINOMA 

OF  THE  CERVIX 

In  the  combined  operation,  the  cervix  is  cauterized  as  before 
but  the  sectioning  of  the  vagina  is  performed  before  the  abdomen 
is  opened.     This  is  accompHshed  by  an  incision  which  encircles 


Fig.    1 88. — Pan-hysterectomy. 


{Wertheim.)     The 
these  clamps." 


vagina  "is    divided    below 


the  entire  vagina  at  as  great  a  distance  from  the  cervix  as  seems 
necessary.  That  portion  of  the  vagina  above  the  circular  in- 
cision is  dissected  free  in  all  directions  until  a  large  cuff  is 
formed  which  is  folded  over  the  cervix  and  sutured  in  position, 


COMBINED    OPERATION  EOR  CARCINOMA 


349 


thus  completely  covering  in  the  diseased  area.  The  lower 
portion  of  the  vagina  is  again  sterilized  by  mopping  with  tinc- 
ture of  iodine  and  packed  with  iodoform  gauze,  when,  after 


Fig.  189. — Pan-hysterectomy.     (Wertheim.)     "Bleeding  from  the  paravaginal 
tissue  is  stopped  by  stitching  around  the  vaginal  stump." 

changing  instruments,  gloves,  etc.,  the  abdomen  is  opened  and 
the  operation  proceeds  as  before  described  until  that  stage  in 
which,  in  the  typical  operation,  the  right-angled  vaginal  clamps 


350     OPERATIONS    UPON   THE   UTERUS   AND   ITS    LIGAMENTS 

are  applied.  When  the  bladder  has  been  stripped  from  the  cervix 
anteriorly  and  the  rectum  from  the  vagina  posteriorly,  the  con- 
nective tissue  around  the  vaginal  mucosa  can  be  readily  sepa- 
rated with  the  finger,  and  the  uterus  and  upper  vaginal  cuff  come 
away  without  the  necessity  for  clamping. 

This  operation  is  advantageous  in  that  sectioning  of  the 
vagina  is  done  from  below  and  the  amount  of  tissue  which  should 
be  removed  can  be  more  accurately  determined,  and  it  also 
locks  up  the  infected  cervix  at  an  early  stage  of  the  operation. 

Especial  points  to  be  noted  in  any  operation  for  cancer  of  the 
cervix  are:  early  exposure  of  the  ureters,  ligation  of  the  uterine 
vessels  external  to  the  ureters,  removal  of  the  entire  para- 
metrium, and  protection  of  the  peritoneum  from  contamination, 
either  by  clamping  the  vagina  as  in  the  Wertheim  operation, 
or  enclosing  the  cervix  in  a  cuff  of  vaginal  wall  as  in  the  com- 
bined operation. 

The  illustrations  accompanying  the  Wertheim  operation  have 
been  redrawn  from  the  article  of  Wertheim's  above  mentioned, 
and  the  legends  are  abstracted  from  his  description  of  the 
operation. 

REFERENCES 

ERDMANN. — Perforation  of  the  Uterus  during  Curettage,  with  Prolapse  of 

Gut,    Necessitating    the    Removal    of    2    Feet    of    Intestine.     Annals    of 

Surg.,  1913,  Ivii,  443. 
SCHUTZE. — Ueber   Perforation    des    Uterus   beim    Curettement.     Zeitsch.  /. 

Geh.  nnd  Gyn.,  191 1,  Ixix,  470. 
FRANK,  R. — Contra-indications  to  Curetting.     N.  York  Med.  /.,  1913,  xcvii, 

808. 
BURCKHARD. — Ueber   den   Wert   der   Probeausschabung  zur   Diagnose   des 

Carcinoma  corporis  Uteri.     Zeitsch.  J.  Geh.  iind  Gyn.,  1913,  Ixxv,  34. 
RICHTER. — Zur    Regeneration    der    Uterusschlcimhaut    nach    Ausschabung. 

Gyn.  Rundschau.,  1914,  viii,  47;  Ahsl.  Internal.  Ahst.  Surg.,  Aug.,  1914. 
WERTHEIM. — Zur  Technik   der   Interpositio   uteri   beim   Prolaps.     Arch.  /. 

Gyn.,  1914,  cii,  201. 
WATKINS. — Transposition  of  the  Uterus  and  Bladder  in  the  Treatment  of 

Extensive  Cystoccle  and  Uterine  Prolapse.     Am.  J.  Obst.,  191 2,  Ixv,  225. 
GOLDSPOHN. — The  Uterus,  W'hy  Vaginofixation,  Ventrofixation,  and  Ventro- 

suspension  Thereof  should  be  Avoided  in  Cases  that  Retain  any  Capacity 

for  Conception.     /.  A.  M.  A.,  1899,  xxxiii,  181. 


REFERENCES  35 I 

SHOEMAKER. — The  Present  Place  of  Vaginal  Hysterectomy  in  Pelvic  Dis- 
orders.   Penn.  M.  /.,  1914,  xviii,  184. 
NAGEL. — Ueber  die  Exstirpatio  uteri  Vaginalis.     Berl.  klin.  Woclt.,  191 2,  xlix, 

1755- 
PRYOR. — The  Technique  of  Vaginal  Hysterectomy  in  Cases  of  Pelvic  Inflam- 
mation.    Am.  Gyn.,  1903,  ii,  102. 
BANDLER.— Fibrosis  Uteri,  and  Its  Surgical  Treatment  by  a  New  Method  of 

Vaginal  Hysterectomy.     Am.  J.  Surg.,  1909,  xxiii,  99. 
MAYO. — Surgical  Treatment  of  Prolapse  of  the  Uterus  and  Walls  of  the  Vagina. 

/.  Am.  Med.  Assn.,  1912,  lix,  1421. 
OUTLAKD. — A  Simplified  Technique  for  Vaginal  Hysterectomy.     /.  A.  M.  A., 

1915,  Ixiv,  1060. 
SIGWART. — The  Technique  of  the  Radical  Operation  of  Cancer  of  the  Uterus. 

J.  F.  Bergmann,  Weisbaden,  Ger.,  191 2. 
MENDES   DE   LEON.— Zur   Alexander-Adams    Operation.     Monais.  f.   Geh. 

und  Gyn.,  1913,  xxxviii,  536. 
PETERSON. — Shortening  of  the  Round  Ligaments  Within  the  Inguinal  Canals 

through  a  Single  Suprapubic  Transverse  or  Median  Longitudinal  Incision. 

Surg.,  Gyn.  b'  Obst.,  1906,  iii,  85. 
GOLDSPOHN. — Intraperitoneal    Shortening    of    the    Round    Ligaments    for 

Retroversion  of  the  Uterus.     /.  A.  M.  A.,  191 1,  Ivi,  573. 
GILLIAM. — Round  Ligament  Ventro-suspension  of  the  Uterus.     Am.  J.  Surg., 

1900,  xlv,  299. 
ILL. — Further  Experiences  with  the  Gilliam  Operation  for  Suspensions.     Trans. 

Am.  Assn.  Obst.  b"  Gyn.,  1912,  xxv,  258. 
CUTHBERTSON.— An  Improved  Gilliam  Operation  for  Uterine  Displacement. 

Surg.,  Gyn.  &'  Obst.,  1914,  xviii,  721. 
MAYO,  C.  H. — The  Technique  of  Shortening  the  Round  Ligaments.     Surg., 

Gyn.  ^  Obst.,  1906,  ii,  203. 
BALDY. — A  New  Operation  for  Retrodisplacement.     /.  of  Obst.,  1902,  xlv,  650. 
BALDY. — Treatment   of   Uterine   Retrodisplacements.     Surg.,  Gyn.    b"   Obst., 

1909,  viii,  421. 
POLAK,  J.  O.— A  Study  of  the  End  Results  of  the  Baldy- Webster  Operation. 

J.  A,  M.  A.,  1913,  Ixi,  1430. 
SIMPSON. — Retroperitoneal  Shortening  of  the  Round  Ligaments.     J.  A.M.  A., 

1911,  Ivi,  553- 
KELLY. — Suspension  of  the  Uterus.     /.  A.  M.  A.,  1895,  xxv,  1079. 
COFFEY. — Plication  of  the  Round  and  Anterior  Fold  of  the  Broad  Ligament 

on  the  Anterior  Surface  of  the  Uterus  for  Retrodisplacement.     J.  A.  M.  A., 

1911,  Ivi,  469. 
SORESI. — A  Simplified  Technique  for  Retrodisplacement  of  the  Uterus  in 

Performing  the  Baldy- W^ebster  Operation.     New  York  M.  J.,  191 1,  xciv,  86. 
OCHSNER. — Temporary    Ventro-suspension    of    the    Uterus.     Surg.,  Gyn,    S* 

Obst.,  1909,  viii,  84. 
FERGUSSON. — Ventro-fixation:  Its  History,  Technique,  Uses,  and  Dangers. 

/.  Obst,  &=  Gyn.,  Brit.  Emp.,  191 2,  xxii,  143. 


352     OPERATIONS   UPON  THE   UTERUS   AND   ITS   LIGAMENTS 

KIRPARSKY. — Der  Vaginale  Weg  in  der  Opera tiven  Behandlung  der  Uterus- 

geschwiilste.     Mon,  f.  Geb.  und  Gyn.,  igio,  xxxii;  Erg.,  8. 
BAER. — Supra-vaginal  Hysterectomy  without  Ligature  of  the  Cervix  in  Opera- 
tion for  Uterine  Fibroids;  A  New  Method.     Am.  J.  ObsL,  1892,  xxvi,  489; 

Jr.  Am.  Gyn.  Soc,  1892,  xvii,  235. 
McMURTRY. — Hysteromyomectomy,   Its   Evolution   and   Perfection.     Surg., 

Gyn.  &"  Obsf.,  1914,  xviii,  556. 
DEAVER. — A  Year's  Work  in  Hysterectomy.     Am.  J.  of  the  Med.  Sciences, 

1913,  cxlv,  469. 
KELLY-CULLEN. — Side  to  Side  Hysterectomy.     Myomata  of  the  Uterus,  1909, 

page  606. 
STONE. — lodin  as  a  Sterilizing  Agent  in  Supra-vaginal  Hysterectomy,  with 

Remarks  upon  Morbidity.     Am.  J.  Obst.,  1914,  Ixxi,  74. 
NEFF. — Dr.  J.   B.   Murphy's  Technique  for  Abdominal  Hysterectomy.     ///. 

M.  J.,  1905,  vii,  172. 
LEONARD. — On  the  Development  of  Malignant  Disease  of  the  Cervical  Stump 

after  Supra-vaginal  Hysterectomy.     Annals  of  Surg.,  1913,  Iviii,  373. 
ALLEN,  D.  P. — Hysterectomy  for  Removal  of  Large  Uterine  Myomata  by  the 

Combined  Vaginal  and  Abdominal  Methods.     BosL  M.  b'  S.  J.,   1898, 

cxxxviii,  485. 
RIES. — Theoretical   and   Practical   Foundations   of   a   Radical   Operation   for 

Carcinoma  of  the  Cervix  Uteri.     /.  A.  M.  A.,  1913,  Ixi,  1256. 
TAUSSIG. — The  Prognosis  in  Radical  Abdominal  Operation  for  Uterine  Cancer. 

Surg.,  Gyn.  b'  Obst.,  191 2,  xv,  147. 
CHILDS. — Abdominal  Pan-hysterectomy  for  Carcinoma  of  the  Cervix  Uteri: 

Its  Technique,  and  the  Advantages  of  Its  Performance  by  Clamp  and 

Cautery.     Brit.  J.  Surg.,  1914,  ii,  11.9. 
BERKELEY  AND  BONNEY.— Results  of  the  Radical  Operation  for  Carcinoma 

of  the  Cervix  Uteri  Based  on  a  Three  Years'  Basis,  More  Especially  with 

Regard  to  Its  Life-prolonging  Effects.     /.  Obst.  b"  Gyn.,  Brit.  Emp,,  1913, 

xxiv,  145. 
CLARK. — The  Radical  Abdominal  Operation  for  Cancer  of  the  Uterus.     Surg., 

Gyn.  b°  Obst.,  1913,  xvi,  255. 
CULLEN. — The  Radical  Operation  for  Cancer  of  the  Uterus.     Surg.,  Gyn.  &* 

Obst.,  1913,  xvi,  265. 


CHAPTER  XI 
DISEASES  OF  THE  UTERINE  TUBES 

The  uterine  tubes  are  developed  from  the  same  foetal  structures 
as  the  uterus,  viz.,  the  Miillerian  tubes.  As  their  histological 
structure  is  strikingly  similar  and  their  physiological  activity 
is  concerned  solely  with  the  process  of  impregnation,  one  would 
expect  a  marked  similarity  in  their  diseases.  Clinically  this  is 
true  of  inflammatory  processes,  but  the  pathological  result  of 
infection  is  strikingly  different  owing  to  the  fact  that  one  end 
of  the  tube  communicates  with  the  peritoneal  cavity,  and  also 
that  the  lumen  of  the  tube  is  so  narrow  and  its  wall  so  thin  that 
it  readily  becomes  occluded  and  distended.  ^ 

Developmental  defects  of  the  tube  are  treated  in  the  chapter 
devoted  to  developmental  defects  in  general. 

Acute  Salpingitis. — Acute  salpingitis,  Hke  acute  endometritis, 
may  have  its  origin  in  either  septic  or  specific  infection.  Septic 
salpingitis  may  be  due  to  extension  of  a  septic  process  outward 
from  the  endometrium,  to  the  extension  of  a  septic  process 
from  the  broad  ligament,  or  to  extension  from  an  acutely 
inflamed  ovary.  An  occasional  infection  of  the  tube  is  due  to 
its  involvement  in  a  pelvic  peritonitis  having  its  origin  in  ap- 
pendicitis or  visceral  perforation.  While  septic  processes  hav- 
ing their  origin  outside  the  female  genitaha  may  be  very 
dangerous,  the  involvement  of  the  tube  is  usually  Hmited  to  its 
peritoneal  coat  and  is  therefore  of  no  immediate  importance, 
although  the  after-results  may  be  adherent  impermeable  tubes 
causing  pain  and  steriHty. 

All  forms  of  septic  inflammation  of  the  tube  are  less  frequent 
than  specific  infection,  the  brunt  of  septic  pelvic  processes  being 
borne  by  the  ovaries,  pelvic  cellular  tissue,  and  peritoneum. 
23  353 


354 


DISEASES    OF   THE   UTERINE    TUBES 


Septic  salpingitis,  therefore,  is  subordinate  in  importance  to 
infection  of  other  tissues  in  which  the  inflammatory  process 
is  more  intense,  and  the  symptoms  and  physical  signs  are  largely 
dominated  by  those  of  oophoritis,  celluhtis,  and  peritonitis. 
Specific  salpingitis,  on  the  other  hand,  is  very  common,  is 


Fig.  190. — Chronic  purulent  salpingitis.  In  this  section  there  is  a  marked 
fibroblastic  proliferation  in  the  wall  of  the  tube  and  likewise  an  infiltration  in  the 
wall  of  the  tube  with  polymorphonuclear  leucocytes.  The  stroma  of  the  folds  is 
markedly  infiltrated  with  jiolymorphonuclears  which  are  gathered  in  many 
places  to  form  small  abscesses.  One  of  these  is  seen  in  the  small  fold  of  the 
central  portion  of  the  field.  The  lumen  of  the  tube  contains  much  pus,  and  we 
have  a  picture  of  a  polymorphonuclear  infiltration  accompanied  by  fibroblastic 
proliferation.     This  is  the  gonorrheal  type  of  purulent  salpingitis. 

productive  of  distinct  pathological  lesions,  and  is  always  due 
to  extension  of  gonorrheal  infection  from  the  mucous  surface 
of  the  uterus  to  the  mucous  surface  of  the  tube.  While 
gonorrhea  of  the  corporeal  endometrium  may  leave  no  evident 
after-effect,  the  results  of  gonorrhea  of  the  tube  are  permanent, 


ACUTE   SALPINGITIS 


355 


and  this  [is  true  even  though  the  gonococci  die  out  rapidly 
once  the  lumen  of  the  tube  becomes  a  closed  cavity.  Pyosal- 
pinx,  chronic  hypertrophic  salpingitis,  hydrosalpinx,  occlusion 
of  the  fimbriated  end,  strictures  throughout  the  course  of  the 
tube,  and  adhesions  to  neighboring  structures,  all  remain  and 


i^^^^f'^ 


Fig.  191. — Chronic  fibroid  salpingitis.  Practically  a  healed  salpingitis.  The 
wall  of  the  Fallopian  tube  is  thickened  because  of  the  proliferation  of  fibrous 
connective  tissue,  the  stroma  of  the  folds  is  also  more  increased  and  more  fibroid 
than  normal  and  the  vessel  walls  thickened.  There  is  no  polymorphonuclear 
infiltration  in  this  material,  but  occasional  plasma  cells  are  to  be  found.  The 
epithelium  is  intact  and  the  lumen  free  from  purulent  exudate. 

are  known  cHnically  as  chronic  salpingitis;  chronic  salpingitis, 
therefore,  is  merely  the  permanent  result  of  the  acute  inflam- 
matory process  which  preceded  it.  In  the  acute  form  of 
specific  salpingitis,  swelHng  of  the  mucosa  of  the  tube  with 
suppuration  of  its  surface  takes  place  very  early,  the  pus 
discharging  from  its  fimbriated  end.     If  the  process  is  so  acute 


356  DISEASES   OF   THE   UTERINE   TUBES 

that  profuse  suppuration  occurs  before  the  fimbriated  end 
becomes  sealed,  a  considerable  quantity  of  pus  may  be  poured 
into  the  pelvic  cavity.  By  reason  of  the  swelKng,  and  also 
through  subsequent  ulceration  of  portions  of  the  tubal  mucosa, 
it  may  be  obstructed  at  various  points  in  its  lumen.  By 
adhesion  of  the  fimbriated  end  to  neighboring  structures,  or, 
what  is  more  common,  by  inversion  of  the  fimbriae  and  adhesion 
of  their  peritoneal  surfaces  to  each  other,  this  end  soon  becomes 
closed  so  that  pus  no  longer  is  discharged  into  the  abdominal 
cavity.  If  the  process  is  very  acute  the  infection  may  extend 
directly  through  the  tube  wall  and  thus  cause  a  local  peritonitis 
in  the  immediate  vicinity,  local  peritonitis  produced  by  one  or 
the  other  or  both  of  these  processes  being  an  inevitable  result  of 
the  hyperacute  type  of  gonorrheal  salpingitis.  In  the  more 
common  less  acute  form,  little  or  no  pus  may  be  discharged 
into  the  peritoneal  cavity,  the  fimbriated  end  of  the  tube  closing 
by  inversion  and  adhesion  of  its  fimbriae  and  direct  extension 
through  the  tube  wall  not  taking  place.  Suppuration  of  the 
tubal  mucosa  is  not  so  profuse  and  no  great  quantity  of  pus  may 
be  retained  within  the  tubal  lumen.  The  tube  wall  may  be 
extensively  infiltrated  and  much  thickened  but  the  lumen  is 
not  greatly  distended.  The  involved  tube  is  usually  prolapsed 
behind  the  uterus,  this  prolapse  being  the  result  of  enlargement 
and  increased  weight  of  the  tube  preceding  its  fixation  by  adhe- 
sions. Should  the  process  be  very  acute  the  tube  may  not 
prolapse,  adhesions  forming  so  rapidly  from  the  irritation  of 
exuded  pus  that  the  tube  remains  fiji:ed  in  its  normal  position, 
but  should  the  process  be  slower,  the  weight  of  the  tube  causes 
it  to  fall  to  the  bottom  of  the  pelvis  where  it  later  becomes 
adherent  through  the  medium  of  the  peritoneal  exudate  which 
is  poured  out  around  it. 

The  characteristic  and  permanent  results  of  tubal  inflam- 
mation are  most  marked  toward  its  abdominal  end.  Many 
instances  of  hydrosalpinx,  pyosalpinx,  and  hypertrophic  sal- 
pingitis are  observed  in  which  that  portion  of  the  tube  near  the 


SYMPTOMS   OF  ACUTE   SALPINGITIS  357 

uterus  is  comparatively  or  entirely  healthy,  and  this  fact  has 
an  important  bearing  upon  the  question  of  the  recurrence 
of  gonorrheal  salpingitis.  This  recurrence  is  not  due,  as 
is  so  frequently  taught,  to  a  Hghting  up  of  the  inflammatory 
process  in  that  portion  of  the  tube  which  was  originally  in- 
volved. On  the  contrary  recurrence  is  similar  in  origin  to  the 
primary  attack,  the  sequence  of  events  being  dependent  upon 
the  fact  that  gonorrhea  of  the  cervix  persists  indefinitely,  and 
over-exertion,  excessive  coitus,  or  unknown  causes  may  result 
at  any  time  in  a  fresh  extension  from  the  cervix  to  the  endome- 
trium of  the  body,  and  thence  outward  to  that  portion  of  the 
tube  which  is  not  already  occluded.  Repeated  attacks  of 
salpingitis  and  pelvic  peritonitis  may  take  place  in  this  manner 
without  further  involvement  of  the  abdominal  end  of  the  tube, 
which  already  is  deprived  of  its  epithehal  coat  and  possibly  so 
distended  and  occluded  as  to  form  a  distinct  pus  sac.  Rupture 
of  the  distended  tube  may  cause  a  second  attack  of  pelvic  per- 
itonitis, but  this  is  much  less  frequent  than  recurrent  inflam- 
mation of  its  uninvolved  portion. 

One  factor,  which  has  an  important  bearing  upon  the  treat- 
ment of  specific  salpingitis,  is  that  the  peritonitis  which  accom- 
panies it  is  local  in  its  character,  gonorrheal  peritonitis  from 
unmixed  gonorrheal  infection  being  almost  unknown  in  the 
adult;  and  a  second  equally  important  factor  is  the  practical 
certainty  that  the  acute  symptoms  sooner  or  later  will  recur. 

Symptoms  and  Clinical  History. — Two  widely  different  cKnical 
pictures  are  presented  by  acute  salpingitis  depending  upon 
whether  the  disease  follows  immediately  upon  an  attack  of  acute 
gonorrhea,  or  whether  it  comes  on  as  a  sequel  of  the  milder  but 
more  common  form  of  latent  gonorrheal  endocervicitis.  In 
the  first,  all  the  evidences  of  acute  pelvic  infection  take  place 
during  or  immediately  succeeding  an  attack  which  was  dis- 
tinctly recognizable  as  acute  vulvar  and  cervical  gonorrhea. 
In  the  second,  the  evidences  of  a  preceding  acute  infection  are 
less,  or  they  may  be  entirely  wanting,  there  having  been  only 


358  DISEASES   OF   THE   UTERINE   TUBES 

a  little  dysuria,  a  trifling  yellowish  leucorrhea,  and  some  in- 
definite pelvic  discomfort. 

In  the  hyperacute  type  the  patient  is  seized  with  severe  pain 
upon  one  side  of  the  pelvis  and  abdominal  distension  soon  oc- 
curs, these  symptoms  being  due  to  a  coincident  peritonitis 
which  is  the  result  of  the  outpouring  of  pus  from  the  suppurating 
tube.  Associated  with  the  pain  and  distension  there  is  sharp 
elevation  of  the  temperature  and  pulse  with  nausea  and  vom- 
iting. Ordinarily  the  very  acute  discomfort  is  short  lived,  and 
there  may  be  a  lull  in  the  symptoms  for  a  day  or  two,  only  to  be 
followed  by  an  exacerbation  in  which  the  pain  is  most  intense 
upon  the  other  side. 

While  the  very  acute  symptoms  last  only  a  few  days  there  is 
some  pain,  tympany,  elevation  of  temperature,  etc.,  for  a  con- 
siderable period.  These  show  a  gradual  subsidence  in  violence 
but  do  not  entirely  disappear  for  several  weeks,  and  even  then 
there  may  be  a  slight  elevation  of  temperature  in  the  evening, 
some  distension  and  discomfort  after  taking  food,  and  alto- 
gether so  much  ill  feeling  that  the  patient  is  confined  to  her  bed 
the  greater  part  of  the  time.  From  this  attack  she  finally  con- 
valesces to  a  stage  of  semi-invalidism  with  pelvic  pain  on  the 
slightest  provocation.  The  first  sharp  attack  of  peritonitis 
is  more  likely  to  occur  during  the  menstrual  period  which  im- 
mediately succeeds  the  attack  of  acute  gonorrhea,  and  it  usually 
results  in  an  increased  prolonged  menstrual  flow. 

Upon  examining  such  a  patient  the  lower  portion  of  the 
abdomen  is  found  hypersensitive  to  the  touch,  the  area  of  hyper- 
aisthesia  corresponding  fairly  well  to  the  area  of  peritoneal  in- 
volvement. Rigidity  of  the  abdominal  muscles  is  made  out, 
although  the  board-like  hardness  which  is  present  in  acute 
appendicular  peritonitis  is  not  usually  in  evidence.  Upon 
vaginal  examination  there  may  be  but  little  of  the  profuse  yel- 
lowish discharge  which  one  would  expect  with  an  acute  gonor- 
rhea, the  sudden  suppression  of  urethral  discharge  at  the  onset 
of  epididymitis  in  the  male  being  paralleled  by  the  sudden  cessa- 


SYMPTOMS   or   SALPINGITIS  359 

tion  of  cervical  and  uterine  discharge  upon  the  occurrence  of 
salpingitis  in  the  female.  On  digital  examination  at  the  onset 
of  the  attack,  nothing  more  may  be  ascertained  than  that  there 
is  extreme  tenderness  and  an  indefinite  sense  of  fullness  at  one 
or  the  other  side  of  and  posterior  to  the  uterus.  This  tenderness 
may  be  so  marked  that  adequate  examination  is  intolerable,  and 
the  collection  of  peritoneal  serum  in  the  pelvic  cavity  may  be 
sufficient  to  obscure  the  outlines  of  the  involved  tube.  Motion 
communicated  to  the  uterus  by  the  finger  is  extremely  painful. 
After  a  few  days  the  serous  peritoneal  exudate  solidifies  and  be- 
comes perceptible  to  the  touch  as  a  gradually  increasing,  fixed, 
pelvic  mass.  With  the  onset  of  suppuration  in  the  other  tube 
tenderness  becomes  more  marked  upon  that  side,  and  the 
quantity  of  fluid  poured  into  the  pelvic  cavity  is  increased  until 
in  the  severest  cases  the  entire  pelvis  may  within  a  few  days  ap- 
pear to  be  choked  by  a  large  firm  mass  which  consists  of  the 
uterus,  tubes,  ovaries,  intestine,  and  omentum  all  glued  together 
by  hard  pelvic  exudate.  As  the  infection  subsides  this  exudate 
gradually  absorbs  and  the  tubes  become  more  plainly  per- 
ceptible, and  after  the  lapse  of  some  weeks  it  may  be  possible 
to  distinctly  outline  a  distended  adherent  tube  on  either  side 
of  or  behind  the  uterus. 

Between  this  hyperacute  type  due  to  virulent  acute  gonor- 
rhea, and  the  very  mild  form  arising  from  an  unsuspected  latent 
focus  in  the  cervix,  there  are  all  grades  of  severity,  but  the  sub- 
acute variety  is  the  one  usually  seen.  In  this  the  patient  may 
at  no  time  have  been  confined  to  bed,  or  at  most  have  been 
incapacitated  for  but  two  or  three  days. 

Investigation  of  the  history  of  patients  with  the  mild  form 
brings  out  the  fact  that  soon  after  marriage  or  a  suspicious  in- 
tercourse some  leucorrhea  and  burning  urination  were  noted, 
and  that  shortly  after  this  there  was  abdominal  and  pelvic  dis- 
comfort which  never  has  entirely  disappeared  and  which  has 
been  subject  to  exacerbations  after  overwork  or  excitement.  The 
pain  usually  has  been  more  severe  upon  one  side  and  seemed  to 


360  DISEASES    OF    THE    UTERINE   TUBES 

make  its  appearance  gradually,  it,  together  with  some  leucorrhea 
and  menorrhagia,  having  persisted  for  several  weeks  or  months 
before  the  patient  presented  herself  for  consultation. 

Upon  abdominal  examination  nothing  may  be  noted  other 
than  a  little  tenderness  in  one  or  the  other  hypogastric  region. 
Upon  vaginal  examination  there  may  or  may  not  be  a  sufficient 
amount  of  discharge  to  arouse  suspicion,  but  stripping  the 
urethra  usually  results  in  the  extrusion  of  a  drop  or  two  of 
muco-purulent  discharge.  The  mouths  of  the  ducts  of  the 
greater  vestibular  glands  may  show  a  small  red  area  and  the 
cervical  mucosa  be  pouting  and  everted,  the  tenacious  cervical 
mucus  being  mixed  with  pus  and  possibly  with  blood. 

Bi-manually  the  uterus  is  found  less  freely  movable  than 
normal,  and  there  is  a  tender  fixed  mass  in  the  cul-de-sac  or  at 
one  or  both  sides  of  the  uterus.  Careful  examination  usually 
elicits  a  mass  on  both  sides,  although  but  one  may  be  apparent 
on  cursory  examination.  Patients  with  this  history  and  such 
physical  findings  may  be  considered  to  have  recurrent  salpin- 
gitis of  a  mild  type,  but  the  ultimate  outcome  is  precisely  the 
same  as  that  following  the  hyperacute  form,  excepting  that 
after  the  latter  the  physical  evidences  are  more  striking  and 
the  patient's  discomfort  more  marked.  These  two  classes,  that 
is,  the  hyperacute  type  after  the  patient  has  recovered  so  far  as 
acute  symptoms  are  concerned  and  the  mild  forms  of  recurrent 
salpingitis,  together  comprise  that  large  class  that  goes  under 
the  general  name  of  chronic  salpingitis^  and  for  this  reason 
separate  consideration  of  the  latter  is  unnecessary. 

Differential  Diagnosis. — In  the  hyperacute  type  the  differen- 
tiation lies  between  salpingitis  and  any  other  possible  cause  of 
acute  pelvic  peritonitis,  but  this  differentiation  is  not  often 
difficult  as,  aside  from  acute  peritonitis  secondary  to  infection  of 
the  ovary  or  the  uterus,  appendicitis  is  practically  the  only 
source  of  acute  pelvic  peritonitis  with  which  it  might  be  con- 
fused. Acute  perforative  appendicitis  has  a  fairly  character- 
istic onset  as  outlined  by  Murphy,  consisting  of  first,  epigastric 


DIFFERENTIAL  DIAGNOSIS   OF  ACUTE   SALPINGITIS        36 1 

pain,  next,  vomiting,  and  last,  elevation  of  temperature.  In 
acute  inflammatory  processes  having  their  origin  in  the  tubes  the 
pain  at  the  onset  is  rarely  in  the  epigastrium,  vomiting  is  not  so 
constant,  and  elevation  of  temperature  may  be  present  before 
either.  On  abdominal  examination  in  early  appendicitis  the 
rigidity  is  confined  to  the  flat  muscles  of  the  right  side,  and  the 
cutaneous  hyperaesthesia  is  located  higher  on  the  abdominal 
wall  than  in  acute  salpingitis.  If,  however,  septic  material 
escapes  from  a  perforated  appendix  and  drains  into  the  pelvic 
cavity  the  well-known  symptoms  of  pelvic  peritonitis  are  im- 
mediately manifested,  and  upon  examining  such  a  patient  bi- 
manually  a  mass  may  be  found  to  the  right  of  the  uterus,  which 
entirely  surrounds  the  tube  and  ovary  of  that  side.  Under 
such  circumstances  a  differential  diagnosis  may  be  almost  or 
quite  impossible.  While  a  gonorrheal  history  does  not  rule  out 
appendicitis,  it  does  make  the  probability  of  salpingitis  much 
stronger.  The  leucocyte  count  in  acute  appendicitis  is  likely 
to  be  higher  than  in  a  salpingitis  presenting  the  same  degree  of 
evidence  of  peritoneal  involvement,  and  if  the  acute  pain  at  the 
outset  was  limited  to  the  left  side  of  the  pelvis  while  a  mass  has 
made  its  appearance  about  the  left  tube  and  ovary,  the  prob- 
ability is  that  salpingitis  rather  than  appendicitis  is  causing  the 
symptoms. 

Having  ruled  out  appendicitis  it  becomes  necessary  to  differ- 
entiate if  possible  between  septic  and  specific  salpingitis,  and 
this  is  accomplished  chiefly  by  the  aid  of  the  history  together 
with  the  presence  or  absence  of  a  gonorrheal  discharge  from  the 
cervix,  urethra,  or  vestibular  glands.  Errors  in  diagnosis,  as 
between  septic  and  specific  salpingitis,  are  more  commonly 
made  because  of  a  wilfully  inaccurate  history  than  for  any  other 
one  reason. 

The  differential  diagnosis  of  the  milder  types  of  acute  sal- 
pingitis which  merge  imperceptibly  into  the  so-called  chronic 
form,  resolves  itself  into  distinguishing  hypertrophic  salpingitis, 
hydrosalpinx,  and  pyosalpinx  from  other  enlargements  in  or 


362  DISEASES    OF   THE   UTERINE   TUBES 

about  the  tube  and  ovary.  A  recurrent  attack  of  mild  sal- 
pingitis is  frequently  mistaken  for  ectopic  pregnancy;  acute 
pain,  slight  elevation  of  temperature,  irregular  menstruation, 
and  a  palpable  tender  mass  at  one  or  the  other  side  of  the 
uterus  being  characteristic  of  both.  Preceding  the  final  rup- 
ture of  an  ectopic  sac  differentiation  is  sometimes  impossible, 
bilateral  disease  speaking  of  course  in  favor  of  salpingitis.  At 
the  time  of  final  rupture  the  evidence  of  internal  hemorrhage  in 
ectopic  pregnancy  is  so  striking  that  an  error  in  diagnosis  is 
hardly  possible.  A  small  ovarian  cyst  readily  becomes  twisted 
upon  its  pedicle  and  is  a  source  of  error  which  it  is  impossible 
to  eliminate,  bilateral  disease  again  being  in  favor  of  sal- 
pingitis. Tuberculosis  of  the  tube  and  ovary  is  an  infrequent 
source  of  error,  and  its  diagnosis  is  likely  to  be  confirmed  by 
free  fluid  in  the  abdominal  cavity,  a  higher  evening  temperature, 
palpable  masses  elsewhere  in  the  abdomen,  and  possibly  the 
finding  of  tuberculous  foci  in  other  parts  of  the  body.  The 
smaller  fixed  tubes  which  are  hardly  palpable  to  the  examining 
finger  are  often  overlooked;  a  trivial  thickening  above  the 
vaginal  vault,  a  little  lessening  of  the  mobility  of  the  uterus, 
and  a  history  of  sterility  extending  over  several  years  being  the 
principal  points  in  diagnosis. 

Prognosis. — The  prognosis  of  acute  septic  salpingitis  is  that 
of  the  disease  to  which  it  is  secondary,  the  tubal  lesion  itself 
being  unimportant.  The  prognosis  of  acute  specific  salpingitis 
in  the  adult  and  outside  the  puerperium  is  entirely  favorable  so 
far  as  life  is  concerned.  In  very  young  children  the  disease  is 
rare  but  dangerous,  and  in  adult  life  if  the  infection  takes  place 
immediately  succeeding  labor  it  is  decidedly  menacing.  While 
under  ordinary  circumstances  the  outlook  as  to  life  is  very  good, 
the  same  cannot  be  said  concerning  restoration  to  health. 
Succeeding  the  very  acute  cases  there  are  usually  weeks  and 
months  of  semi-invalidism,  with  slight  elevation  of  temperature 
at  night,  much  abdominal  distress,  and  an  occasional  profuse 
menorrhagia.     More  or  less  constant  discomfort  may  persist 


TREATMENT   OF   SALPINGITIS  363 

indefinitely  with  occasional  acute  attacks  which  are  similar  to  but 
not  so  severe  as  the  first  one.  Any  physical  changes  which  are 
found  a  few  months  after  acute  specific  salpingitis  subsides 
may  be  considered  to  be  permanent,  restoration  of  the  integrity 
of  the  tube  being  practically  unknown.  The  same  is  true 
of  the  milder  form  although  the  patient's  discomfort  is  rarely 
so  great,  recurrences  are  not  so  severe,  and  menorrhagia  is  only 
an  occasional  symptom,  but  pelvic  distress  is  persistent,  in  the 
sense  that  while  it  may  not  occur  daily  or  even  monthly,  it 
inevitably  returns.  It  can  be  said  confidently  that  complete 
resolution  of  a  well-defined  case  of  specific  salpingitis  is  not  to 
be  expected,  and  that  the  lesions  produced,  although  they  may 
vary  from  time  to  time,  are  permanent  and  incurable  by  any 
method  short  of  operation. 

Treatment  of  Salpingitis. — The  early  treatment  of  acute  septic 
salpingitis  is  that  of  the  primary  disease;  later  it  may  be  that  of 
acute  pelvic  peritonitis  with  pus  formation.  The  treatment  of 
specific  salpingitis  resolves  itself  into  the  treatment  of  the 
acute  attack,  whether  primary  or  recurrent  is  immaterial,  and 
the  treatment  of  the  distorted,  occluded,  adherent  tubes  which 
are  left.  The  treatment  of  specific  salpingitis  during  the  acute 
attack  is  distinctly  palliative  and  medical,  surgical  interference 
at  this  time  being  not  only  unnecessary  but  associated  with  a 
high  morbidity  as  well  as  a  perceptible  death  rate.  The  primary 
indications  are  to  assist  nature  in  her  efforts  to  localize  the 
infection,  and  to  keep  the  patient  comfortable  until  the  acute 
process  has  run  its  course.  To  fulfill  the  first,  cathartics  are 
avoided  and  the  bowels  are  kept  open  by  enemas  only.  The 
diet  is  of  such  a  character  as  to  put  the  least  tax  on  the  digestive 
organs  and  leave  the  smallest  amount  of  debris  in  the  intestinal 
tract.  The  patient  should  be  sent  to  bed  and  should  remain 
there  during  the  entire  duration  of  the  disease,  every  motion  of 
the  body  tending  to  distribute  the  infection  beyond  its  original 
location.  Local  applications  to  the  abdomen  appear  to  relieve 
the  pain,  cold  being  more  generally  useful  than  heat,  although 


364  DISEASES   OF  THE   UTERINE   TUBES 

in  the  later  stages  heat  is  often  borne  better  than  cold.  Local 
applications  through  the  vagina  in  the  form  of  hot  douches, 
applications  to  the  cervix  and  uterus,  tampons,  etc.,  are  not 
only  useless  but  are  very  annoying  to  the  patient  and  interfere 
with  the  first  principle  of  treatment,  which  is  rest.  Excessive 
pain  should  be  relieved  by  the  use  of  opiates,  morphia  or  codia 
being  preferable  to  opium  because  they  are  less  constipating, 
and  while  the  patient  should  not  be  kept  narcotized  she  should 
not  be  allowed  to  suffer.  No  fear  need  be  entertained  of  setting 
up  a  narcotic  habit  if  opiates  are  used  only  during  the  acutely 
painful  stage  of  the  disease.  The  temperature  is  rarely  high 
enough  to  need  any  consideration,  and  antipyretics  are  not 
necessary  for  the  relief  of  fever  although  some  of  them  are 
useful  for  their  analgesic  properties  when  the  pain  is  not  so 
severe  as  to  demand  morphine. 

The  natural  tendency  to  operate  when  a  palpable  swelling 
makes  its  appearance  in  the  pelvis,  or  the  recto-uterine  ex- 
cavation presents  a  bulging  mass,  should  not  be  acceded  to 
unless  there  is  a  mixed  infection  and  distinct  evidence  of  a  pelvic 
abscess  pointing  toward  the  posterior  vaginal  fornix.  Under 
the  latter  circumstance  incision  and  drainage  are  indicated, 
but  in  a  pure  gonococcus  infection  the  patient  will  recover  just 
as  rapidly  if  this  is  avoided,  and  moreover,  she  will  be  without 
the  risk  of  a  permanent  tubo-vaginal  fistula.  Radical  operation 
with  extirpation  of  the  diseased  tube  or  tubes  during  the  acute 
stage  is  advised  by  some  authorities,  but  there  are  many  valid 
objections  to  this  procedure.  Operation  in  the  midst  of  acute 
infection  is  more  hazardous  than  in  the  cold  stage,  is  far  more 
bloody,  and  drainage  is  more  often  necessary.  In  addition 
to  this,  the  swollen  ocdematous  condition  of  the  ovaries  makes  it 
impossible  to  tell  whether  or  not  they  are  hopelessly  diseased, 
and  their  extirpation  is  likely  to  be  practised  if  operation  is 
performed  at  this  time,  whereas  after  the  acute  symptoms  have 
subsided  it  usually  will  be  found  that  one  or  both  can  be  re- 
tained with  safety.     It  occasionally  happens  that  after  the 


TUBERCULOSIS   OF   THE   TUBES  365 

subsidence  of  the  very  acute  symptoms  a  patient  will  continue 
to  have  a  little  evening  elevation  of  temperature,  the  pain  will 
be  quite  severe  with  intermissions  and  exacerbations,  emaciation 
is  progressive,  and  on  the  whole  the  operative  risk  appears  to 
be  justified  by  the  continued  suffering.  Only  under  such  cir- 
cumstances should  one  advise  radical  operation  during  either 
the  actue  or  subsiding  stage  of  acute  specific  salpingitis. 

In  chronic  cases  the  pain  caused  by  adhesions,  distorted 
displaced  tubes,  hydrosalpinx,  and  pyosalpinx  may  be  relieved 
temporarily  by  palliative  treatment  if  for  any  reason  it  seems 
judicious  to  tide  the  patient  over  for  a  time  before  resorting 
to  radical  operation;  on  the  other  hand,  the  victims  of  this 
condition  should  understand  that  such  palliative  methods  result 
in  nothing  better  than  the  relief  of  discomfort,  and  that  per- 
manent cure  is  not  to  be  anticipated  from  anything  short  of 
removal  of  the  diseased  organs.  Prolonged  hot  douches,  taken 
while  the  patient  is  in  a  reclining  position,  and  counterirrita- 
tion  to  the  vaginal  vault  and  anterior  abdominal  wall  give  some 
relief  from  pain.  Glycerin  tampons  snugly  applied  to  the 
vaginal  fornices  are  of  value  in  relieving  discomfort,  but  the 
routine  adoption  of  these  measures  with  the  idea  of  complete 
cure  is  chimerical,  and  leads  only  to  disappointment  and  loss 
of  confidence  on  the  part  of  the  patient. 

Tubercixlosis  of  the  Tubes. — Tuberculous  inflammation  of 
the  uterine  tubes  is  a  common  forerunner  of  tuberculous  peri- 
tonitis. Unfortunately  it  rarely  is  discovered  before  the  latter 
affection  is  in  full  swing,  and  no  pathognomonic  evidence  of 
tuberculous  salpingitis  can  be  depended  upon  to  establish  a 
diagnosis  before  the  symptoms  of  tuberculous  peritonitis  have 
become  quite  plain.  The  symptoms  and  physical  findings  are 
essentially  those  of  tuberculous  peritonitis  with  which  there  is 
associated  a  palpable  tumor  at  one  or  both  sides  of  the  uterus. 
Pain,  evening  elevation  of  temperature,  marked  emaciation, 
night  sweats,  free  or  encysted  fluid  in  the  abdominal  cavity, 
masses  of  exudate  palpable  through  the  abdominal  wall,  and 


366 


DISEASES   OF   THE    UTERINE    TUBES 


especially  the  rolled  up  adherent  omentum  to  be  felt  at  or  near 
the  umbilicus;  these,  together  with  a  positive  tuberculin  reac- 
tion, are  the  principal  evidences  of  the  latter  disease.  A  sign 
of  some  value  is  the  peculiarly  full  rounded  abdomen,  which 
is  almost  always  present  and  which  is  in  striking  contrast  to 
the  general  thinness  of  the  patient.     When  with  these  one 


Fig.   192. — Chronic  tuberculosis  of  Fallopian  tube.     There  are  numerous  miliary 
tubercles  in  the  section,  the  most  prominent  containing  a  large  giant  cell. 


finds  a  palpably  enlarged  tube  or  tubes,  it  is  safe  to  assume 
that  the  peritoneal  infection  had  its  origin  in  these  organs. 

The  treatment  of  tuberculous  salpingitis  is  that  of  tuberculous 
peritonitis  plus  the  removal  of  the  diseased  tubes,  providing 
the  patient's  general  physical  condition  is  such  as  to  justify 
operation  at  all.  In  that  form  of  tuberculous  peritonitis  in 
which  ascites  is  a  marked  feature,  abdominal  incision  and  evacua- 


SALPINGECTOMY  367 

tion  of  the  fluid  without  drainage  is  sometimes  productive  of 
great  good.  When  no  free  fluid  is  present  the  result  of  opening 
the  abdomen  is  far  less  favorable,  but  if  the  abdomen  is  opened 
at  all,  removal  of  the  tubes  adds  but  little  to  the  risk  involved 
unless  the  adhesions  are  dense,  and  their  separation  time 
consuming  and  dangerous  to  the  integrity  of  the  intestine. 

The  general  treatment  of  tuberculous  peritonitis  associated 
with  or  dependent  upon  tuberculous  salpingitis  is  that  of  tuber 
culosis  in  general ;  rest  as  long  as  elevation  of  temperature  per- 
sists, absolute  open-air  treatment,  and  as  much  nutritious  food 
as  the  patient's  digestive  organs  can  manage.  When  lapar- 
otomy with  removal  of  the  tubes  can  be  practised  early  in  the 
course  of  the  disease  and  be  followed  by  a  systematic  open-air 
cure  the  prognosis  is  relatively  quite  favorable.  When  the 
disease  has  progressed  to  the  stage  of  hectic  fever,  marked 
emaciation,  and  rapid  feeble  pulse,  medical  treatment  without 
operation  is  more  likely  to  be  satisfactory  although  the  outlook 
in  these  cases  is  distinctly  a  desperate  one. 

Actual  new  growths  of  the  tube  are  rare  and  not  often  diag- 
nosed until  after  the  abdomen  is  opened,  and  their  diagnosis 
therefore  need  not  be  dwelt  upon. 

SALPINGECTOMY 

The  removal  of  the  uterine  tubes  for  the  results  of  in- 
flammatory disease  is  the  most  common  major  operation 
in  pelvic  surgery.  When  the  tubes  are  occluded  but  free 
from  dense  adhesions  the  operation  is  simple,  while  the  re- 
moval of  a  large  densely  adherent  pyosalpinx  which  has  per- 
forated into  the  rectum  or  bladder  is  one  of  the  most  difficult 
undertakings  in  surgery.  Upon  opening  the  abdomen  under  the 
latter  circumstances  one  may  be  confronted  by  old  adhesions 
roofing  over  the  entire  pelvic  cavity,  and  these  may  cover  a 
dense  mass  consisting  of  the  pelvic  organs,  omentum,  small  and 
large    intestine,    and    bladder.     The    inexperienced    operator 


z(>^ 


DISEASES   OF   THE   UTERINE   TUBES 


should  make  it  his  first  business  to  determine  whether  or  no  he 
is  capable  of  extirpating  the  diseased  organs.  It  is  better  to 
close  the  abdomen  at  once  than  to  break  up  adhesions,  injure 
viscera,  and  then  find  that  the  case,  so  far  as  he  is  concerned,  is 
inoperable.  Should  it  be  determined  to  proceed,  the  first  step 
is  the  separation  of  adhesions  and  demonstration  of  the  dis- 
eased tubes.     The  omentum  should  be  clamped  and  ligated  if 


Fig.  193. — Chronic  salpingitis  with  adhesions.  Distended  right  tube  adherent 
in  normal  position.  Left  tube  buried  in  old  adhesions.  Uterus  drawn  to  left 
by  adhesions  to  sigmoid. 

the  adhesions  are  old  and  dense,  or  separated  with  the  fingers  if 
recent.  As  soon  as  the  omentum  is  released,  it,  together  with 
any  coils  of  free  intestine,  should  be  lifted  out  of  the  pelvic  basin 
and  a  wall  of  gauze  pads  be  so  arranged  as  to  keep  the  intestine 
from  crowding  into  the  operative  field,  and  at  the  same  time 
prevent  soiling  of  the  upper  abdomen  with  any  pus  that  may 
be  encountered.  A  line  of  cleavage  between  the  adherent  tube 
and  adjoining  pelvic  structures  should  be  sought  with  the 


SALPINGECTOMY 


369 


finger.  In  long-standing  cases  this  at  first  may  seem  impossible, 
but  perseverance  in  attacking  first  one  point  and  then  another, 
even  incising  with  the  knife  between  visible  coils  of  adherent 
intestine  and  the  pelvic  structures,  finally  enables  the  experi- 
enced operator  to  determine  the  line  of  separation  and  outline 
the  distended  tube.     It  cannot  too  often  be  repeated  that  sepa- 


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Fig.  194. — Chronic  salpingitis  with  adhesions.  One  distended  tube 
anterior  to  uterus,  the  other  posterior.  The  result  of  "hyperacute  gonor- 
rheal salpingitis." 

ration  of  adhesions  should  be  done  with  gentleness,  and  that 
even  with  the  greatest  care  an  opening  may  be  made  into  the 
bowel  or  bladder.  Should  such  an  accident  happen  the  dam- 
aged viscus  is  to  be  repaired  at  once.  Occasionally  a  case  is 
encountered  in  which  a  coil  of  intestine  is  so  involved  in  the 
inflammatory  mass  that  its  sacrifice  is  necessary,  and  an 
24 


370 


DISEASES   OF   THE    UTERINE    TUBES 


operator  who  is  not  capable  of  performing  intestinal  resection 
has  no  right  to  undertake  an  operation  upon  old  pus  tubes  which 
have  undergone  repeated  attacks  of  inflammation.  As  the 
separation  of  adhesions  proceeds,  the  released  intestine  should 
be  packed  off  with  gauze  pads  so  that  that  portion  of  the  pelvis 
in  which  the  work  is  being  prosecuted  may  at  all  times  be  free 
from  intestinal  coils.  Eventually  the  fingers  can  be  insinuated 
under  the  diseased  tube,  whose  lowest  boundary  is  usually  found 
at  the  bottom  of  the  pelvic  cavity.     The  separation  of  the  tube 


Fig.  195. — Salpingectomy.  Anterior  view.  On  the  left,  both  tube  and 
ovary  are  clamped.  On  the  right,  the  external  clamp  is  placed  between  the  tube 
and  ovary. 


from  the  rectum  and  posterior  surface  of  the  broad  ligament 
should  be  continued  with  care,  as  the  rectum  is  easily  torn  and 
the  large  veins  in  this  locality  are  readily  injured.  When  all 
adhesions  have  been  separated  and  the  tube  and  ovary  are 
drawn  up  in  plain  view,  it  remains  to  be  determined  whether 
the  ovary  shall  be  sacrificed  with  the  tube.  In  many  cases  it 
is  of  advantage  to  separate  the  adhesions  oh  both  sides  and  ex- 
amine both  ovaries  before  deciding  this  question.  If  one  ovary 
appears  to  be  relatively  healthy  excepting  for  the  raw  surface 
left  after  separating  the  adhesions  to  its  surface,  plans  can  be 


SALPINGECTOMY 


371 


made  for  its  retention,  while  a  badly  diseased  ovary  upon  the 
other  side,  or  one  distorted  by  adhesions  and  cyst  formation, 
can  be  removed.  An  understanding  with  the  patient  upon  this 
point,  viz.,  the  removal  of  the  ovaries,  should  be  arrived  at  be- 
fore operation,  as  most  women  prefer  the  retention  of  one  or  a 
portion  of  one  ovary  even  at  the  risk  of  a  second  operation,  while 
others  have  suffered  so  severely  that  they  will  take  no  chances 
and  prefer  that  a  clean  sweep  be  made  rather  than  to  incur  the 


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Fig.  186. — Salpingectomy.  Anterior  view.  The  left  broad  ligament  has 
been  clamped  and  the  ligatures  laid  but  not  tied.  The  right  tube  has  been 
removed  and  the  interlocking  ligatures  tied. 


possibility  of  another  operation  later.  If  the  ovary  is  to  be 
sacrificed  and  the  patient  is  not  in  good  condition  because  the 
early  steps  of  the  operation  have  been  prolonged,  the  simplest 
method  for  the  removal  of  the  tubo-ovarian  mass  should  be 
adopted.  This  consists  in  perforation  of  the  meso-salpinx 
at  its  middle,  ligation  of  the  outer  end  of  the  broad  ligament 
external  to  the  ovary  with  one-half  a  double  ligature,  and  liga- 
tion of  the  inner  end  of  the  broad  ligament  together  with  the 


372 


DISEASES   or   THE  UTERINE   TUBES 


tube  at  its  junction  with  the  uterus  with  the  other  half.  The 
tube  and  ovary  are  cut  away  and  any  small  bleeding  points  in 
the  meso-salpinx  caught  and  tied.  A  somewhat  safer  method, 
which  is  equally  rapid,  consists  in  placing  a  clamp  on  the  outer 
end  of  the  broad  ligament  beyond  the  ovary,  and  another  on  the 
inner  end  of  the  broad  ligament  including  the  uterine  extremity 
of  the  tube,  the  points  of  the  clamps  meeting  on  the  meso- 
salpinx below  the  tube.     The  tubo-ovarian  mass  is  then  excised 


Fig.  197. — Salpingectomy.     Anterior  view.     A  neater  method  than  the  pre- 
ceding in  which  the  tubal  stump  is  excised  from  the  uterine  horn. 


distal  to  the  clamps  and  the  broad  ligament  tied  with  two  liga- 
tures, one  placed  just  behind  the  outer  clamp  and  the  other  just 
behind  the  inner.  Each  clamp  should  be  loosened  as  the  first 
knot  is  drawn  down,  and  the  clamp  be  entirely  removed  as  soon 
as  it  is  found  that  the  knot  is  tight  and  the  thread  not  likely 
to  break.  A  neater  method  of  operating  should  be  used  when 
time  is  of  no  special  moment.  This  consists  of  clamping  the 
ovarian  vessels  at  the  outer  end  of  the  broad  ligament  external 
to  the  ovary,  excising  the  uterine  end  of  the  tube  from  the 


SALPINGECTOMY 


373 


uterine  wall,  clamping  the  utero-ovarian  artery  just  beneath  this 
point,  cutting  away  the  tubo-ovarian  mass,  and  clamping  any 
small  vessels  that  spurt  in  the  mid-portion  of  the  broad  ligament. 
The  operation  is  completed  by  tying  all  vessels  and  whipping 
over  the  top  of  the  broad  ligament  with  a  continuous  catgut 
stitch.  In  this  manner  but  little  raw  surface  is  left  to  contract 
adhesions  to  the  intestine  or  omentum,  and  the  tube  is  so  re- 
moved that  no  stump  remains  to  give  further  trouble.  If  the 
ovary  is  to  be  retained,  the  clamp  or  ligature  applied  to  the 


Fig.  198. — Salpingectomy.     Anterior  view.     "The  operation  is  completed  by 
tying  all  vessels  and  whipping  over  the  top  of  the  broad  ligament." 

outer  end  of  the  broad  Hgament  should  be  placed  between  the 
ovary  and  tube.  Ligation  of  the  ovarian  artery  external  to  the 
ovary  produces  so  much  disturbance  of  its  nutrition  that  more 
or  less  subsequent  pain  and  degeneration  of  the  ovary  with 
cyst  formation  is  to  be  anticipated.  As  the  stump  is  short,  the 
ligature  between  the  tube  and  ovary,  whether  placed  before  or 
after  clamping,  must  be  very  carefully  applied  and  it  is  a  wise 
safeguard  to  whip  this  over  with  a  fine  catgut  stitch  after  the 
Hgature  is  tied.  Both  tubes  having  been  removed,  it  may  be 
found  that  injured  veins  are  bleeding  upon  the  posterior  surface 


374  DISEASES    OF   THE   UTERINE   TUBES 

of  the  broad  ligaments.  These  should  be  caught  separately 
and  either  tied  with  plain  catgut  or  closed  with  sutures  of  the 
same  material,  emphasis  being  laid  upon  the  necessity  for  using 
plain  gut  because  the  anatomical  relations  are  so  distorted 
that  it  is  possible  to  include  the  ureter  in  a  ligature,  or  kink 
it  by  a  suture  placed  in  its  immediate  vicinity.  If  the  suture  is 
of  plain  gut  it  will  absorb  at  an  early  date  and  result  in  no  perma- 
nent damage.  Haemostasis  so  far  as  it  concerns  distinct  vessels 
must  be  absolute,  and  the  abdomen  should  not  be  closed  until 
every  one  is  controlled.     Those    sponges  which  were  intro- 


FiG.  199. — Salpingectomy.  If  there  is  but  little  induration  in  the  broad 
ligament  the  external  and  internal  ligatures  may  be  so  drawn  together  as  to 
leave  no  raw  surface. 

duced  to  control  oozing  and  fill  the  space  from  which  adherent 
intestine  was  removed,  are  now  withdrawn  and  replaced  by  a 
dry  pad,  which  holds  the  intestine  away  from  the  site  of  opera- 
tion while  the  pelvic  cavity  is  sponged  dry  and  inspected. 
When  it  is  certain  that  active  bleeding  has  stopped,  the  pos- 
terior wall  of  the  uterus,  the  posterior  layers  of  the  broad  Kga- 
ment,  the  bottom  of  the  pelvic  cavity,  and  the  top  of  the  blad- 
der are  thoroughly  sponged  off  with  saline  solution.  Intestine 
which  was  packed  away  from  the  pelvis  after  adhesions  were 
loosened  is  again  inspected  to  be  certain  that  no  damaged  spot 


DRAINAGE    AFTER   SALPINGECTOMY 


375 


is  overlooked.  The  sigmoid  is  then  dropped  behind  the  uterus, 
the  omentum  drawn  behind  the  incision  but  not  into  the  pelvis, 
and  the  abdomen  closed  with  or  without  drainage.  The  sub- 
ject of  drainage  is  considered  in  the  chapter  devoted  to  gynaeco- 
logic  surgery,  but  in  a  general  way  it  may  be  said  that  the  re- 


FiG.  200. — Salpingectomy  followed  by  vaginal  drainage. 

gauze  cofferdam. 


Superior  view  of  the 


action  against  abdominal  drainage  has  gone  too  far.  Drain- 
age, of  course,  need  not  be  practised  after  the  removal  of  old 
pus  tubes  unless  there  are  extensive  raw  surfaces  which  cannot 
be  adequately  covered  with  normal  peritoneum,  and  from 
which  oozing  is  persistent.     This  is  true  even  if  the  tubes  have 


376  DISEASES   OF   THE   UTERINE   TUBES 

ruptured,  as  the  contents  of  old  pus  tubes  are  sterile.  But 
in  more  recent  cases  in  which  a  doubt  exists  as  to  the  sterility  of 
the  contents  of  the  tube,  as  well  as  when  there  is  doubt  as  to  the 
integrity  of  the  rectal  wall,  drainage  does  no  harm  and  may 


Fig.  201.— Salpingectomy  followed  by  vaginal  drainage.  Sagittal  section 
showing  gauze  cofferdam.  The  general  abdominal  cavity  is  shut  off  from  the 
lesser  pelvis. 

obviate  the  necessity  for  opening  an  abscess  or  evacuating  a 
haimatoma,  and  may  even  prevent  an  attack  of  virulent  general 
peritonitis.  Such  drainage  may  be  made  through  the  vagina, 
and  for  this  purpose  iodoform  gauze  is  the  best  material,  the 


SALPINGECTOMY  377 

plan  of  its  use  being  to  pack  the  cul-de-sac  tightly  with  one  end 
of  the  strip,  to  lightly  fluff  the  remainder  of  the  gauze  into  the 
cavities  from  which  the  tubes  have  been  removed  and  over 
any  possible  infected  areas  including  the  broad-ligament 
stumps,  and  then  to  drop  the  sigmoid  over  the  gauze.  Thus 
the  general  abdominal  cavity  is  completely  shut  off  from  the 
lesser  pelvis.  After  the  abdomen  is  closed  the  patient  is  placed 
in  the  lithotomy  position,  and  without  making  traction  upon  the 
cervix,  the  vaginal  wall  immediately  posterior  to  it  is  seized  with 
volsellum  forceps  and  incised  transversely  with  scissors  to  the 
extent  of  3  or  4  cm.  The  connective  tissue  between  the  vaginal 
wall  and  the  peritoneum  and  the  peritoneum  itself  is  then 
torn  through,  when  the  tightly  packed  end  of  the  gauze  can  be 
drawn  into  the  vagina.  Another  strip  of  iodoform  gauze  is 
placed  in  the  vagina  with  its  outer  end  protruding  through  the 
vulva.  A  large  abdominal  pad  is  placed  over  the  vulva,  and 
during  convalescence  every  care  is  taken  that  the  vulvar  dress- 
ings are  as  aseptically  handled  as  would  be  the  dressings  if 
the  drain  were  through  the  anterior  abdominal  wall.  Iodoform 
is  advised  rather  than  plain  gauze  since  it  inhibits  saprophytic 
infection  and  decomposition,  and  the  gauze  is  odorless  even  if 
retained  a  week  or  10  days. 

Special  Points  of  Technique. — i.  Careful  walKng  off  of  the 
general  abdominal  cavity  from  that  portion  in  which  the 
operation  is  to  be  performed. 

2.  Great  gentleness  in  the  separation  of  adhesions. 

3.  Immediate  repair  of  any  opening  into  the  viscera. 

4.  Complete  haemostasis.  Secondary  hemorrhage  does  not 
take  place  from  vessels  which  are  adequately  tied. 

5.  The  removal  of  the  tube  complete,  healthy  as  well  as 
diseased  portion. 

6.  The  covering  of  the  stump  and  raw  surfaces  as  far  as 
possible  with  healthy  peritoneum. 

7.  The  drawing  of  the  sigmoid  into  the  pelvic  cavity  so  that 
small  intestine  may  not  occupy  this  space  and  become  adherent. 


378  DISEASES    OF   THE   UTERINE   TUBES 

8.  ''When  in  doubt  drain,"  according  to  the  old  formula. 

After-care. — The  after-care  is  that  of  abdominal  section  in 
general.  The  patient  should  be  returned  to  a  bed  the  foot  of 
which  is  moderately  elevated.  In  this  way  oozing  is  minimized, 
pain  diminished,  and  to  some  extent  the  fixation  of  small  in- 
testine in  the  pelvic  cavity  is  prevented. 

Shock  is  rarely  met  with;  when  it  is,  or  when  hemorrhage 
has  been  severe  enough  to  seem  to  indicate  saline  solution  per 
rectum,  it  may  be  so  used  providing  the  rectum  has  not  been 
injured.  Should  the  rectum  have  been  damaged,  it  is  wise  to 
dilate  the  anus  before  the  patient  regains  consciousness  and 
have  a  small  rectal  nozzle  constantly  in  place  to  prevent  pres- 
sure of  gas  upon  the  injured  area,  and  enemas  for  the  relief  of 
distension  or  to  open  the  bowels  should  be  small  and  given 
without  pressure  for  the  same  reason. 

There  is  no  objection  to  the  use  of  moderate  doses  of  narcotics 
for  post-operative  pain. 

If  drainage  has  been  practised  a  small  piece  of  vaginal  gauze 
should  be  withdrawn  and  cut  off  after  each  urination,  and  the 
vulva  should  be  irrigated  after  each  urination  and  defecation. 

The  vaginal  gauze  may  all  be  removed  within  two  or  three 
days,  but  the  strip  which  has  been  placed  in  the  abdomen  should 
be  left  for  a  week  or  more.  Early  removal  is  painful  and  pro- 
ductive or  fresh  bleeding,  and  retention  of  the  gauze  lo  or  12 
days  does  no  harm  providing  the  opening  in  the  vaginal  vault 
is  liberal  and  has  not  been  plugged  by  careless  placing  of  the 
drain. 

The  catheter  should  be  used  only  if  spontaneous  urination  is 
impossible. 

REFERENCES 

HEYNEMANN.— Zur  Aetiologie  der  Pyosalpinx.     Zcil.  f.  Gch.  und  Gyn.,  191 2, 

Ixx,  870. 
MacNAUGHTON-JONES.— The  Relation  of  the  Appendix  to  the  Causation 

and  Surgical  Treatment  of  Affections  of  the  Adnexa.     Proc.  Roy.  Soc.  Med., 

191 1 ;  Obsl.  &•  Gyn.  Sec,  341. 


REFERENCES  379 

Von  ROSTHORN. — Appendicitis  und  Erkrankungen  der  Adnexa  Uteri.    Monats. 

f.  Geb.  und  Gyn.,  1909,  xxx,  280. 
VEST. — A  Clinical  Study  of  Primary  Carcinoma  of  the  Fallopian  Tube.     Johns 

Hopkins  Hosp.  Bull.,  1914,  xxv,  305. 
GOTH. — Klinische  Studie  ueber  700  Falle  von  entziindlichen  Adnextumoren. 

Arch.  f.  Gyn.,  1910,  xcii,  300. 
REDER. — ^Laceration  of  the  Cervix,  a  Causative   Factor   in  Salpingitis.     Am. 

J.  Ohst.,  1913,  Ixviii,  902. 
BOLDT. — Diseases  of  the  Fallopian  Tubes.     J.  A.  M.  A.,  191 2,  Ux,  100. 
OCHSNER. — Appendicitis  as  a  Cause  of  Inflammatory  Disease  of  the  Right 

Tube  and  Ovary.     /,  A.  M.  A.,  1899,  xxxiii,  192. 
WEISHAUPT. — Zusammenhang  von  Aetiologie  und  Histologie  der  Salpingitis. 

Arch.  f.  Gyn.,  1914,  ci,  65. 
PLOEGER. — Zur  Histologie  entziindlicher  Tubenerkrankungen  mit  besonderer 

Beriicksichtigung  der  gonorrhoischen.     Arch.f.  Gyn.,  191 2,  xcv,  634. 
RABINOVITZ. — The  Pathogenesis  of  Adenomyosalpingitis  (Salpingitis  Nodosa). 

Am.  J.  Ohst.,  1913,  Ixviii,  711. 
HAUSMANN. — Ergebnisse  der  methodischen  Palpation  der  Ileocoecalgegend 

mit   besonderer    Beriicksichtigung   der   ektopischen    Eileiter.     Monats.  f. 

Geb.  und  Gyn.,  1914,  xxxix,  772. 
NEU. — Zur  spezifischen  Diagnostik  und  Therapie  der  weiblichen  Adnexgonorrhoe. 

Monats.  f.  Geb.  tend  Gyn.,  1913,  xxxvii,  182. 
ANSPACH. — The  Torsion  of  Tubal  Enlargements  with  Especial  Reference  to 

Pyosalpinx.     Am.  J.  Obst.,  191 2,  Ixvi,  553. 
CLARK,  ALONZO. — Peritonitis.     Pepper's  System  of  Medicine,  1885,  ii,  1132. 
SIMPSON. — The  Choice  of  Time  for  Operation  for  Pelvic  Inflammation  of 

Tubal  Origin.     Surg.,  Gyn.  &"  Obst.,  1909,  ix,  45. 
MARKOWSKY. — Zur  Frage  der  Behandlung  der  Adnexerkrankungen  mittelst 

Coeliotomia   vaginalis.     Monats.  f.   Geb.   und  Gyn.,    1910,    xxxii;    Ergdn- 

zungsheft,  18. 
AMBERGER. — Beitrag  zur  Operativen  Behandlung  der  entzundlichen  Adnexer- 
krankungen   und    ihren    Beziehiingen    zur   Peritonitis.     Beitrag.  f.    Klin. 

Chirurg.,  1915,  xcv,  272. 
FARBACH. — Specific  Treatment  of  Pyosalpinx.     Med.  Rec,  191 2,  Ixxxi,  662. 
SCHLIMPERT. — Die  Tuberkulose  bei  der  Frau,  Auf  Grund  von  3514  Sektionen. 

Arch.f.  Gyn.,  1911,  xciv,  863. 
KELLER. — Histologische  Untersuchungen  ueber  den  Infektions  weg  bei  der 

weibHchen  Adnextuberkulose.     Arch.f.  Gyn.,  1912,  xcviii,  253. 
JAYLE. — ^Tubercular  Salpingitis.    Presse  med.,  1913,  xxi,  505.     Abst.  Internal. 

Absf.  Surg.,  March,  1914,  283. 
BARBOUR  AND  WATSON.— Tuberculous  Pyosalpinx.    /.  ObsL  b'  Gyn.  Brit. 

Emp.,  191 1,  XX,  105. 
LABHARDT. — Beitrage   zur   Genital   und   Peritonealtuberkulose.    Zeitsch.  f. 

Geb.  und  Gyn.,  1912,  Ixx,  532. 


380  DISEASES   OF   THE   UTERINE   TUBES 

PAHL  AND  OLIVIER. — De  la  therapeutique  conservatrice  daus  le  traitment  de 

la   tuberculose    annexielle.     Rev.    de.  gynec.  et  chir.  abdom.,  1913,  xxi,  23. 

Abst.  Internal.  Abst.  Surg.,  191 4. 
SCHMIDT,  O. — Die  operative  Behandlung  der  Peritoneal  und    Genitaltuber- 

kulose.     Zeitsch.  f.  Geb.  und  Gyn.,  1913,  Ixxiii,  405. 
SCHURMANN. — Die    systematische    Tampondrainage    des   kleinen    Beckens 

zur  Vorbeugung  gegen  postoperativ   Peritonitis.     Zentralb.  f.  Gyn.,  1910, 

xxxiv,  1019. 
BALDWIN,  J.  T. — Methods  of  Drainage  in  Pelvic  and  Abdominal  Surgery. 

Trans.  Am.  Assn.  Obst.  6°  Gyn.,  1909,  xxii,  229. 
BOVEE,  J.  WESLEY.— Gynaecologic  Pelvic  Drainage.     /.  A.  M.  A.,  191 2,  lix, 

249. 


CHAPTER  XII 
EXTRA-UTERINE  PREGNANCY 

The  startling  features  of  a  pregnancy  outside  the  womb,  the 
cataclysmic  character  of  severe  intra-abdominal  hemorrhage, 
and  the  brilliant  results  of  proper  treatment  combine  to 
render  this  subject  one  of  perennial  interest.  Ectopic  preg- 
nancy is  not  rare  as  in  the  work  of  the  average  surgeon  many 
cases  are  seen  in  the  course  of  a  si*igle  year,  and  it  is  probable 
that  many  others  occur  in  which  the  death  of  the  ovum  takes 
place  at  so  early  a  date  that  the  symptoms  are  trivial  and  the 
correct  diagnosis  is  not  made. 

Etiology. — Ectopic  pregnancy  primarily  is  practically  always 
tubal.  Attempts  have  been  made  to  prove  the  possibility  of 
primary  ovarian  pregnancy,  and  a  few  cases  have  been  reported 
which  bear  out  this  contention,  but  theoretically  only  the 
uterine  and  tubal  mucosa  are  fitted  to  receive  an  ovum,  permit 
its  implantation,  and  undergo  such  changes  as  to  allow  of  its 
complete  development,  although  the  decidual  reaction  has 
been  proven  to  occur  on  the  ovary,  as  well  as  on  the  external 
surface  of  the  uterus  and  other  peritoneal-covered  surfaces. 
When  the  tube  ruptures  or  the  ovum  is  expelled  from  its  ab- 
dominal end,  a  sufficient  area  of  chorion  may  remain  adherent 
to  the  tubal  mucosa  to  permit  continued  life  of  the  ovum. 
In  this  event  the  foetus  develops  in  the  abdominal  cavity, 
and  the  pregnancy  may  properly  be  considered  as  abdominal 
although  the  primary  point  of  attachment  of  the  chorion  to 
the  decidua  was  in  the  tube.  It  is  conceded  that  we  do  not 
know  precisely  how  the  developing  placenta  overflows,  as 
it  were,  from  the  tubal  mucosa  and  becomes  implanted  upon 
the  ovary  and  the  peritoneum  covering  the  pelvic  structures, 

381 


382  EXTRA-UTERINE   PREGNANCY 

but  we  know  that  such  implantation  does  take  place  and  that 
separation  of  the  placenta  from  this  attachment  leads  to  terrific 
hemorrhage. 

Obviously  it  is  impossible  to  determine  with  certainty  the 
point  of  junction  of  the  spermatozoid  and  ovule  in  the  human 
being,  but  investigation  in  the  lower  animals  leads  us  to  believe 
that  this  takes  place  regularly  in  the  tube.  It  is  not  difficult, 
therefore,  to  understand  how  tubal  implantation  of  the  ovum 
might  occur  in  the  event  that  the  ciliated  epithelium  failed  to 
convey  the  impregnated  ovum  through  the  tube  to  the  uterus. 
This  failure  may  be  due  to  a  congenital  anomaly  by  which  a 
portion  of  the  tube  is  not  lined  with  ciliated  epithelium,  or  to  a 
congenital  dilatation  in  which  the  ovum  lodges,  or  to  a  stric- 
ture which  it  cannot  pass.  We  can  also  understand  how  a  mild 
salpingitis  causing  denudation  of  the  tubal  epithelium  may 
leave  the  impregnated  ovum  stranded  in  some  portion  of  the 
tube  distal  to  the  uterus.  The  conditions  under  which  a  tube  is 
removed  for  extra-uterine  pregnancy  are  such  that  adequate 
investigation  as  to  the  ultimate  etiology  is  impossible,  but  the 
theoretical  conception  of  some  trifling  tubal  disease  which  has 
destroyed  the  ciliated  epithelium  or  led  to  strictures  in  the  tube 
probably  is  correct  for  the  greater  number  of  cases.  The  fact 
that  tubal  pregnancy  repeats  itself  on  the  other  side  far  more 
frequently  than  it  occurs  in  women  who  have  never  been  the 
victims  of  this  condition  points  in  the  same  direction, 
although  the  presence  of  several  abnormally  placed  "decidual 
reaction"  sites  would  also  account  for  this  phenomenon. 

Life  History  of  the  Extra-uterine  Ovum.^The  great  variety 
of  end  results  in  extra-uterine  pregnancy,  and  the  widely  different 
clinical  pictures  presented  by  a  number  of  cases,  are  most  readily 
understood  by  a  short  account  of  what  actually  may  happen 
after  the  implantation  of  an  impregnated  ovum  in  the  tube. 
The  trophoblastic  action  of  the  ovum,  which  leads  it  to  behave  as 
a  parasite,  and  imbed  itself  in  the  mucosa  anywhere  from  the 
fimbriated  end  to  that  portion  in  the  uterine  cornua,  explains 


LIFE   HISTORY   OF   EXTRA-UTERINE    OVUM 


383 


many  of  the  phenomena  which  follow.  In  addition,  the  thin 
muscular  wall  of  the  tube  undergoes  distension  at  an  early 
date  and  this  distension  may  result  in  its  actual  rupture, 
although  one  might  conceive  of  a  case  in  which  trophoblastic 
activity  did  not  result  in  perforation  and  the  tubal  muscle 
hypertrophied  so  promptly  that  no  rupture  occurred,  in  which 
event  a  full-term  tubal  pregnancy  would  follow.  More  fre- 
quently, however,  this  trophoblastic  action  of  the  ovum  sufhces 
to  produce  a  small  perforation  and  from  this  a  little  hemorrhage 
takes  place.     The  original  perforation  may  be  minute,  but  the 


Fig.  202. — Extra-uterine  pregnancy.     Note  site  of  chorionic  attachment. 


continued  growth  of  the  ovum  stretches  the  opening  and,  if 
the  ovum  Kves,  its  continued  trophoblastic  action  sooner  or  later 
results  in  enlarging  the  perforation  and  so  producing  recurrent 
hemorrhage  into  the  pelvic  cavity.  Separation  of  the  ovum 
from  its  attachment  may  take  place  at  any  time  and  cause  its 
death  before  perforation  of  the  tube,  and  with  this  separation 
some  hemorrhage  through  the  fimbriated  end  is  certain  to  occur. 
The  ovum  is  a  foreign  body,  and  foreign  bodies  in  the  tube 
probably  cause  contraction  of  the  tube  precisely  as  they  do  in 
the  uterus;  thus  should  the  ovum  become  sufficiently  separated, 
its  expulsion  from  the  abdominal  ostium  may  take  place,  so- 


384 


EXTRA-UTERINE   PREGNANCY 


called  tubal  abortion,  and  this  is  especially  likely  to  happen 
if  the  primary  site  of  implantation  is  near  the  outer  end  of  the 
tube.  Continued  growth  of  the  ovum  may  result  in  actual 
rupture  of  the  tube  with  opening  of  some  of  the  larger  ves- 
sels and  very  severe  intra-abdominal  hemorrhage.  Again,  the 
ovum  may  be  extruded  into  the  abdominal  cavity  but  still 
retain  a  sufhcient  area  of  chorionic  attachment  to  furnish  it  with 


Fig.  203. — Extra-uterine  pregnancy.     Unruptured  tube. 


nutrition,  in  which  event  the  ovum  may  live  and  a  foetus 
develop  in  the  abdominal  cavity.  More  commonly  the  ovum 
dies  and  undergoes  ultimate  absorption.  The  ovum,  there- 
fore, may  continue  to  live  and  develop  in  the  tube  until  it 
attains  foetal  maturity,  or  it  may  be  expelled  dead  or  alive  from 
the  abdominal  end  of  the  tube.  If  alive  when  expelled,  it  may 
die  at  once  or  continue  to  develop,  or  the  tube  may  rupture  at 


LIFE   HISTORY   OF   EXTRA-UTERINE    OVUM 


385 


any  portion  of  its  circumference  with  extrusion  of  the  ovum 
through  the  perforation,  the  ovum  living  if  a  sufficient  amount 
of  placental  attachment  remains,  or  dying  if  the  placental 
attachment  is  insufficient.  If  the  foetus  lives  after  extrusion 
in  any  manner  it  may  go  on  until  full  term  when  false  labor 
takes  place,  after  which  the  foetus  invariably  dies.  The  foetus 
may  die  at  any  period  of  its  career,  or  the  amniotic  sac  in  which 


Fig.  204. — Extra-uterine  pregnancy.     Specimen  illustrates  perforation  of  tube 

with  two  vessels  opened. 


the  foetus  is  retained  after  its  expulsion  from  the  tube  may  at 
any  time  undergo  rupture.  The  effused  blood  in  the  abdominal 
cavity  may  be  absorbed,  or  it  may  fail  of  absorption,  become 
infected,  and  give  rise  to  a  localized  abscess. 

A  moment's  consideration  of  this  rather  complicated  series 

of   possibilities   explains   why   the    history   differs   so   widely 

in  different  cases,  and  leads  one  to  understand  how  the  clinical 

course  may  vary;  why  there  may  be  sudden  death  within  the 

25 


386 


EXTRA-UTERINE   PREGNANCY 


Fig.  205. — Extra-uterine    pregnancy.     Drawing  from  specimen  after  opening 
unruptured  tube.     Tubal  mole — the  ovum  died  in  tube. 


Fig.  206. — Extra-uterine    pregnancy.     vSi)ccimcn   in    which   tubal   abortion   is 
taking  place.     Note  clot  in  fimbriated  end  of  tube. 


LIFE  HISTORY   OF   EXTRA-UTERINE   OVUM 


387 


first  six  or  eight  weeks  of  pregnancy,  or  all  the  vicissitudes  of 
tubal  abortion  or  tubal  rupture  with  recurring  hemorrhage 
from  time  to  time;  why  there  may  be  an  illness  extending  over 
g,  10,  or  II  months  with  the  symptoms  of  pregnancy,  the 
development  of  a  full-term   foetus,    false   labor,    retention   of 


Fig.  207. — Extra-uterine  pregnancy.  Drawing  from  specimen  after  opening 
tube  and  sac  which  had  been  extruded  from  fimbriated  end  of  tube.  "Tubal 
abortion — the  ovum  alive." 


the  foetus  and  membranes  in  the  abdominal  cavity,  fatty  de- 
generation of  the  foetus,  or  infection  of  the  sac  and  its  contents 
with  expulsion  of  foetal  parts  through  the  bladder  or  intestine, 
together  with  the  prolonged  sepsis  arising  from  the  latter 
condition. 


388  EXTRA-UTERINE   PREGNANCY 

SYMPTOMATOLOGY  AND  DIAGNOSIS 

The  symptomatology  and  diagnosis  of  extra-uterine  pregnancy 
can  best  be  studied  by  sketching  the  early  history  of  a  so-called 
typical  case  (it  being  understood  that  typical  cases  are  in  the 
minority),  and  thereafter  discussing  the  symptoms  and  physical 
signs  which  are  presented  with  an  estimate  of  their  proper  value 
in  diagnosis. 

In  such  a  typical  case  uninterrupted  menstruation  extends 
over  a  period  of  years  and  is  succeeded  by  a  missed  menstrual 
period,  the  cessation  of  menstruation  being  to  the  lay  mind 
such  conclusive  evidence  of  pregnancy  that  the  patient  considers 
herself  pregnant.  Two  or  three  weeks  after  the  missed  men- 
strual period,  that  is  six  or  seven  weeks  from  the  last  regular 
menstruation,  the  patient  is  conscious  of  a  little  pelvic  pain  upon 
one  or  the  other  side,  and  shortly  after  the  onset  of  this  pain 
there  is  a  trivial  menstrual  flow.  Since  any  sort  of  discomfort 
is  expected  by  patients  who  are  pregnant  for  the  first  time,  no 
apprehension  is  excited  by  the  pain  so  long  as  it  is  moderate  and 
easily  borne.  The  pain  is  usually  colicky  in  character,  it  may 
be  fairly  sharp  and  last  but  a  short  time  only  to  recur  at  intervals 
over  a  period  of  several  days,  and  rather  indefinitely  corresponds 
in  the  time  of  its  appearance  to  the  menstrual  ''spotting." 
In  from  six  to  10  weeks  after  the  last  regular  menstrual  period 
the  patient  is  seized  with  very  severe  pain  and  faints,  and  sim- 
ultaneously there  appear  other  evidences  of  shock  or  hemorrhage 
or  both.  At  this  time  the  pulse  becomes  soft,  usually  very  fast, 
but  sometimes  slow,  the  mucous  membranes  are  blanched,  and 
the  temperature  drops  below  normal.  Within  a  few  hours  re- 
action occurs,  the  pulse  becomes  fuller,  color  returns  to  some 
extent,  and  as  the  air-hunger  subsides  the  patient  becomes 
quieter  and  more  comfortable. 

From  this  time  on  no  set  of  symptoms  can  be  considered 
typical,  such  a  variety  of  events  as  may  occur  in  the  abdomen 
necessarily  leading  to  a  marked  diversity  of  symptoms,  but  up 


SYMPTOMS   AND  DIAGNOSIS  389 

to  the  time  of  actual  perforation,  tubal  rupture,  or  tubal  abor- 
tion, a  fair  proportion  of  cases  will  present  about  the  course 
outlined  above. 

An  analysis  of  the  signs  and  symptoms  is  perhaps  best  made 
by  grouping  them  as  follows,  the  term  ''rupture"  as  used, mean- 
ing perforation,  tubal  abortion  or  tubal  rupture,  each  of  these 
being  associated  with  intra-abdominal  hemorrhage:  Preceding 
rupture — at  time  of  rupture — immediately  following  rupture — 
late  extra-uterine — the  fcetus  dead,  the  foetus  alive. 

Preceding  Rupture.- — Previous  Sterility.- — The  classical 
history  of  sterility  is  present  in  a  fair  proportion  of  cases  pre- 
ceding the  occurrence  of  extra-uterine  pregnancy,  and  if  this 
sterility  has  existed  over  a  number  of  years  the  evidence  is 
of  value  by  itself  as  it  makes  the  probability  of  extra-uterine 
pregnancy  greater,  but  fecundity  is  of  no  value  whatever  in 
excluding  extra-uterine  pregnancy,  since  the  latter  may  occur  in 
women  who  are  bearing  children  regularly.  In  one  instance  the 
author  operated  for  extra-uterine  pregnancy  upon  a  patient  who 
was  still  nursing  her  last  child.  A  history  of  sterility  is  of  some 
weight,  therefore,  in  a  patient  who  presents  other  symptoms  of 
extra-uterine  pregnancy,  but  the  absence  of  such  history  is 
without  value.  The  sudden  cessation  of  menstruation  in  a 
patient  who  was  previously  regular,  and  who  has  subjected  her- 
self to  the  possibility  of  impregnation,  is  one  of  the  strong 
presumptive  evidences  of  pregnancy,  either  intra-  or  extra- 
uterine. Should  there  be  added  to  this  a  history  of  preceding 
sterility  over  a  long  period,  a  certain  value  is  given  to  the  mere 
skipping  of  one  menstrual  period  if  there  is  no  other  known  cause 
for  menstrual  suppression.  While  normal  pregnancy  may  take 
place  after  years  of  sterility,  it  is  so  unusual  that  this  combina- 
tion should  lead  one  to  regard  the  occurrence  with  suspicion. 
However,  menstruation  may  be  perfectly  normal  even  though 
tubal  pregnancy  exists,  so  that  regular  menstruation  is  not 
conclusive  evidence  against  early  extra-uterine  pregnancy,  nor 
is  regular  menstruation  any  excuse  for  neglecting  to  take  extra- 


3  go  EXTRA-UTERINE   PREGNANCY 

uterine  pregnancy  into  account  when  any  symptoms  are  pre- 
sented which  might  lead  one  to  suspect  its  existence. 

Irregular  Flow  Following  a  Missed  Menstrual  Period. — ^A 
missed  menstrual  period  by  itself  may  mean  much  or  may  mean 
little,  but  the  onset  of  a  scanty  flow,  coming  drop  by  drop, 
skipping  a  day  or  two  and  beginning  again,  two  or  three  weeks 
after  menstruation  should  have  occurred  is  always  significant 
of  something.  This  something  may  be  nothing  more  than  a 
suppressed  period  due  to  any  of  the  thousand  and  one  causes  of 
temporary  suppression,  but  the  occurrence  of  menstruation  after 
ordinary  suppression  is  so  likely  to  be  deferred  but  a  few  days, 
or  else  to  occur  at  the  proper  time  for  the  next  menstrua- 
tion, that  its  onset  midway  between  the  expected  dates  is  full 
of  significance. 

Again,  a  missed  period  followed  by  intermenstrual  spotting 
may  be  due  to  a  threatened  early  abortion,  and  the  passing  of 
decidual  would  lend  color  to  such  a  supposi  tion,  but  decidua  forms 
in  the  uterus  though  the  pregnancy  be  tubal,  and  small  shreds 
are  almost  invariably  cast  off  in  conjunction  with  the  associated 
flow.  This  combination,  sterility,  a  missed  menstruation  and 
recurrence  of  menstruation  after  six  or  seven  weeks,  together 
with  expulsion  of  decidua  from  the  uterus,  is  quite  as  good 
evidence  of  extra-uterine  pregnancy  as  of  early  abortion. 

Pain  before  Rupture. — Exceptionally  there  may  be  no  pain 
whatever  until  the  time  of  final  rupture  with  its  intense  pain 
and  profound  collapse;  more  commonly,  however,  the  patient 
has  a  little  colicky  pain  on  that  side  upon  which  the  pregnant 
tube  is  situated.  The  pain  is  not  constant  and  is  of  short 
duration.  If  it  occurs  in  a  patient  who  has  never  been  pregnant, 
it  may  be  explained  to  her  mind  by  the  presumed  pregnancy, 
or  if  she  thinks  that  pregnancy  is  impossible,  the  pain  may  be 
referred  directly  to  the  incident  which  she  thinks  is  responsible 
for  the  suppression  of  menstruation.  As  the  perforation  in 
the  tube  grows  larger  and  the  hemorrhage  from  time  to  time 
becomes  more  severe,  the  attacks  of  pain  are  more  serious  in 


SYMPTOMS   AND  DIAGNOSIS  39I 

character  although  usually  short  lived,  but  by  themselves  they 
may  be  sufficiently  annoying  so  that  the  patient  applies  for 
examination  before  final  rupture  of  the  tube. 

The  combination  of  a  missed  menstrual  period,  irregular 
spotting,  and  recurrent  colicky  pain  associated  with  the  passing 
of  shreds  of  tissue,  has  led  to  more  than  one  curettage  for  pre- 
sumed abortion,  instead  of  which  the  most  careful  examination 
should  have  been  made  to  exclude  the  possibility  of  ectopic 
pregnancy. 

Physical  Signs  before  Rupture. — Upon  abdominal  examina- 
tion nothing  distinctive  is  presented.  There  may  be  a  little 
hyperaesthesia  and  rigidity  over  the  affected  side  but  nothing 
more. 

Per  vaginam  some  of  the  ordinary  evidences  of  pregnancy  may 
be  found,  a  little  purple  discoloration  below  the  urethra,  slight 
softening  of  the  cervix,  and  some  enlargement  of  the  uterus. 
Upon  the  side  of  the  involved  tube  a  very  tender  elastic  mass 
is  palpable  on  bi-manual  examination  providing  the  patient  is 
not  too  sensitive.  This  mass  is  small,  corresponds  to  the  loca- 
tion of  the  tube,  and  is  always  exquisitively  sensitive  to  pressure. 

Thus  it  will  be  seen  that  the  history  of  a  missed  menstruation, 
a  little  irregular  flow,  decidual  discharge,  and  colicky  pain, 
together  with  the  results  of  a  physical  examination  at  this  early 
period,  simulate  very  closely  an  abortion  with  trifling  ovarian 
inflammation.  It  is  at  this  point  that  the  history  of  preceding 
sterility  is  of  such  great  significance,  especially  when  combined 
with  the  positive  knowledge  that  no  attempt  has  been  made  to 
induce  abortion.  Sterility,  followed  by  the  other  symptoms 
described  and  associated  with  exquisite  tenderness  of  a  tubal 
mass,  pressure  upon  which  reproduces  the  pain  of  which  the 
patient  complains,  is  so  suggestive  of  extra-uterine  pregnancy 
that  an  exploratory  opening  through  the  vaginal  vault  is  in- 
dicated should  it  be  required  in  order  to  confirm  the  diagnosis. 

Should  there  be  marked  discrepancies  in  the  history,  no 
sterility,  no  missed  menstruation,  and  no  irregular  spotting, 


392  EXTRA-UTERINE   PREGNANCY 

the  diagnosis  rarely  will  be  made  until  one  severe  hemorrhage 
has  taken  place,  but  no  patient  who  is  presumed  to  have  aborted 
should  be  subjected  to  any  intra-uterine  manipulation  until  a 
careful  bi-manual  examination  has  excluded  tubal  pregnancy. 

Symptoms  at  Time  of  Rupture. — Usually  some  of  the  above- 
noted  symptoms  of  tubal  pregnancy  will  have  preceded  those 
now  to  be  described.  It  is  not  at  all  necessary  that  all  of  them 
should  have  existed,  the  absence  of  one  or  more  being  quite 
common,  and  occasionally  the  first  evidence  of  anything  wrong 
is  sudden  collapse  of  the  patient  with  symptoms  of  concealed 
hemorrhage.  Much  more  frequently,  however,  the  slight 
colicky  pain  has  continued  until,  upon  arising  in  the  morning, 
going  to  the  toilet,  or  lifting,  there  is  excruciating  pelvic  pain 
during  which  the  patient  becomes  faint  or  loses  consciousness. 
At  this  time  the  extremities  are  cold,  the  visible  mucous  mem- 
branes are  blanched,  and  the  pulse  is  very  soft  and  usually 
rapid,  although  it  may  sometimes  be  very  slow. 

At  this  point  it  must  be  remembered  that  the  pain  and 
collapse  are  not  entirely  due  to  loss  of  blood,  but  that  they  are 
partially  dependent  upon  the  shock  of  sudden  extravasation 
of  fluid  into  the  abdominal  cavity.  That  this  is  capable  of 
producing  all  the  symptoms  of  shock  can  be  proven  experi- 
mentally by  pouring  fluid  into  the  abdomen  of  a  non-anaes- 
thetized patient. 

Unless  the  blood  loss  is  excessive  reaction  occurs  within  a 
few  hours,  and  a  latent  period  then  ensues  before  the  hemorrhage 
recurs.  At  the  time  of  collapse  the  temperature  is  sub-normal, 
during  reaction  it  may  be  markedly  elevated  although  the 
patient  is  still  anaemic  and  the  haemoglobin  far  below  normal. 
This  reaction  temperature  is  analogous  to  the  aseptic  wound 
fever  which  follows  any  operation,  and  it  confuses  the  picture 
customarily  painted  of  ruptured  tubal  pregnancy. 

Examination  at  this  time  often  is  rendered  unsatisfactory 
by  the  extreme  restlessness  and  confused  condition  of  the 
patient's  mind,  even  if  she  is  not  wholly  unconscious. 


SYMPTOMS   AND  DIAGNOSIS  393 

The  abdomen  usually  will  be  found  tympanitic  superior  to  a 
transverse  line  which  corresponds  to  the  upper  level  of  effused 
blood.  Marked  flatness  or  even  dullness  below  this  line  may  not 
be  made  out,  but  just  above  it  there  is  an  area  of  marked  tym- 
pany which  shades  off  in  both  directions,  up  as  well  as  down. 
Vaginally  it  may  be  possible  to  make  out  the  slightly  en- 
larged uterus  with  an  indefinite  sense  of  fullness  above  the 
posterior  vaginal  fornix,  and  a  mass  may  be  palpable  at  one 
or  the  other  side  of  the  uterus.  Exquisite  tenderness  again  is 
a  startling  feature  even  on  gentle  palpation.  A  few  hours 
after  the  rupture,  some  clotting  of  the  effused  blood  and  the 
traumatic  peritonitis  about  it  makes  the  pelvic  findings  more 
distinct. 

Each  succeeding  hemorrhage  presents  a  picture  correspond- 
ing to  the  first  and  differing  only  in  its  intensity,  while  the 
interval  between  hemorrhages  is  featured  by  improvement  in 
the  patient's  condition. 

Diagnosis  at  the  Time  of  Rupture. — While  intestinal  perfora- 
tion or  strangulation  may  give  raise  to  pain  equally  severe,  and 
may  be  associated  with  shock  and  collapse,  the  evidences  of 
internal  hemorrhage  are  lacking.  The  surface  of  the  body 
may  be  pale  and  cold,  but  the  mucous  membranes  are  not 
blanched  nor  the  haemoglobin  so  reduced  as  in  hemorrhage. 

Vomiting  too  is  a  prominent  feature  of  strangulation,  and 
although  common  enough  in  extra-uterine  pregnancy,  it  is  not 
one  of  the  predominant  symptoms  of  the  latter. 

The  history  of  a  menstrual  anomaly  which  has  led  to  the  pre- 
sumption of  pregnancy  after  prolonged  sterility,  if  followed 
by  evidence  of  acute  internal  hemorrhage  and  pelvic  pain,  is 
sufficient  to  justify  a  presumptive  diagnosis  of  ruptured  extra- 
uterine pregnancy,  and  this  diagnosis  becomes  positive  if  any 
of  the  above-enumerated  physical  evidences  can  be  elicited. 

If  the  hemorrhage  and  shock  do  not  cause  immediate  death 
of  the  patient,  a  latent  period  may  follow  in  which  the  pain  per- 
sists although  not  so  severe,  the  symptoms  of  acute  anaemia 


394  EXTRA-UTERINE   PREGNANCY 

gradually  subside,  and  the  temperature  becomes  elevated,  some- 
times as  high  as  ioi°  or  io2°F.,  while  the  pulse  regains  some 
of  its  normal  quality.  Menstrual  spotting  continues  and  por- 
tions of  decidua  may  be  discharged  from  time  to  time. 

Abdominal  examination  at  this  time,  a  few  hours  after  the 
first  sharp  hemorrhage,  shows  the  same  distinct  line  of  tympany 
across  the  abdomen  and  the  same  hypersensitiveness  over  the 
lowermost  portion  of  the  anterior  abdominal  wall,  and  on  vaginal 
examination  there  is  an  indefinite  sense  of  fluid  exudate  in  the 
pelvis,  with  or  without  a  distinct  palpable  mass.  Again,  the 
diagnosis  is  almost  positive  even  if  the  patient  is  not  seen  until 
reaction  occurs,  providing  a  history  is  obtained  of  a  menstrual 
anomaly,  supposed  pregnancy,  etc.,  followed  by  abrupt  pain 
and  fainting. 

The  latent  period  may  last  but  a  few  hours  or  extend  over 
several  days  when  a  recurrence  of  the  hemorrhage  may  take 
place,  followed  by  another  rally,  then  another  hemorrhage, 
reaction  and  relapse  alternating  so  long  as  a  living  ovum  is 
contained  in  the  perforated  or  ruptured  tube,  and  ending  only 
with  expulsion  of  the  ovum  from  the  tube  or  the  death  of  the 
patient. 

After  Rupture,  the  Ovum  Dead. — Should  death  of  the  ovum 
take  place,  the  patient  continues  to  have  pain,  but  not  of  the 
acute  type  above  described.  The  effused  blood  may  clot  and 
form  a  ha^matoma  which  is  walled  in  by  adhesions,  the  ultimate 
end  in  favorable  cases  being  absorption  of  the  clot.  In  other 
instances  the  blood  fails  to  coagulate,  absorption  of  only  a 
portion  taking  place  while  the  greater  part  becomes  enclosed 
in  adhesions  at  the  bottom  of  the  pelvis,  thus  giving  rise  to  the 
encysted  collection  of  fluid  blood  which  is  known  technically  as 
an  ha^matocele.  In  favorable  cases  this  will  gradually  absorb, 
or  on  the  other  hand  it  may  become  infected  and  give  rise  to  a 
pelvic  abscess  with  localized  peritonitis. 

Diagnosis  at  this  time  is  dependent  upon  an  accurate  history 
in^which  pain,  collapse,  and  acute  anaemia  are  the  significant 


SYMPTOMS   AND   DIAGNOSIS 


395 


features,  since  examination  reveals  nothing  but  a  semi-solid  mass 
(the  haematoma)  or  a  fluctuating  collection  of  fluid  (the  haem- 
atocele)  in  the  recto-uterine  excavation. 

After  Rupture,  the  Ovum  Living. — Very  exceptionally  the 
ovum  continues  to  live  and  go  on  to  further  development.  In 
such  cases  the  foetus  is  surrounded  by  the  amniotic  sac  which 
encloses  it  as  in  normal  pregnancy,  but  as  this  sac  is  unprotected 
by  the  muscular  wall  of  the  uterus  it  is  easily  ruptured  when  the 
placenta  becomes  partially  or  completely  separated,  and  sudden 


Fig.  208. — Extra-uterine  pregnancy.     Haematocele  posterior  to  uterus  due  to 
walling  in  of  blood  which  has  not  coagulated. 

death  of  the  patient  may  occur  from  the  enormous  hemorrhage 
which  ensues. 

It  is  rare  that  ectopic  pregnancy  goes  to  full  term,  and  when 
it  does  the  foetus  is  likely  to  be  deformed  or  poorly  developed. 
At  the  expiration  of  the  usual  nine  months  of  gestation  labor 
pains  occur,  after  which  the  placental  circulation  ceases  with 
the  death  of  the  foetus,  which  may  either  mummify,  be  con- 
verted into  adipocere,  or  become  infected,  and  give  rise  to 
general  sepsis. 


396  EXTRA-UTERINE   PREGNANCY 

It  is  plain  that  while  the  symptoms  may  vary  somewhat  dur- 
ing this  time,  the  evidences  of  pregnancy  will  continue  so  long  as 
the  foetus  lives.  Added  to  the  ordinary  symptoms  of  preg- 
nancy, however,  there  is  pain,  not  necessarily  severe  but  of  a 
type  that  does  not  accompany  normal  pregnancy.  The 
abdomen  enlarges,  but  the  enlargement  is  not  symmetrical, 
having  its  origin  to  one  or  the  other  side  of  the  mid-line. 
In  the  middle  three  months  of  pregnancy  examination  will 
reveal  the  breast  symptoms  of  pregnancy  (always  unreliable) 
and  an  enlarged  abdomen,  and  bi-manually,  the  uterus  while 
larger  and  softer  than  normal  does  not  correspond  in  size  and 
consistency  to  the  presumed  duration  of  pregnancy.  To  one 
side  of  the  uterus  will  be  found  an  elastic  swelling  which 
corresponds  in  size  to  the  presumed  duration  of  gestation, 
and  under  favorable  circumstances  ballottement  may 'be  made 
out  in  this  sac. 

As  pregnancy  proceeds,  foetal  motion  and  foetal  heart  sounds 
become  noticeable  as  in  normal  pregnancy,  but  both  are 
remarkably  distinct,  foetal  motion  appearing  so  plain  as  to  give 
the  impression  that  it  is  directly  underneath  the  skin  of  the 
abdominal  wall. 

At  the  time  of  false  labor  the  pains  are  in  all  respects  like 
those  of  normal  labor  excepting  that  they  are  less  severe  and 
are  protracted  over  a  period  of  several  days.  With  the  onset 
of  labor  pains  there  is  some  ''show/'  and  pieces  of  decidua 
may  appear  in  the  uterine  discharge.  Examination  at  this 
time  reveals  the  cervix  somewhat  softened,  but  still  so  much 
firmer  than  the  cervix  of  a  full-term  pregnant  uterus  that  sus- 
picion should  be  aroused  at  once.  If  the  uterus  can  be  outlined 
at  all  in  the  tense  abdomen  it  is  found  to  be  larger  than  normal, 
but  quite  plainly  it  does  not  contain  the  foetus.  It  is  often 
impossible  to  feel  the  fundus  and  body  of  the  uterus,  and  if 
there  is  a  strong  suspicion  of  extra-uterine  pregnancy  the 
introduction  of  the  sound  is  justifiable,  upon  which  it  will  be 
found  that  the  uterus  is  but  10  or  12  cm.  in  depth. 


PROGNOSIS  397 

It  will  be  seen  that  after  the  first  three  or  four  months  the 
diagnosis  is  comparatively  easy  if  normal  pregnancy,  or  normal 
pregnancy  plus  a  pelvic  tumor,  can  be  excluded.  The  diagnosis 
of  pregnancy  having  been  established,  whether  it  is  intra-  or 
extra-uterine  can  be  determined  by  the  exercise  of  a  little 
patience,  as  no  matter  how  thin  the  muscular  uterus  may  be 
it  undergoes  alternate  contraction  and  relaxation.  Repeated 
abdominal  palpation  sooner  or  later  will  estabHshed  the  fact 
that  the  foetal  parts  are  contained  in  a  contracting  surrounding 
envelope  in  normal  pregnancy,  while  if  the  foetus  is  outside  the 
uterus  no  such  alternating  contraction  and  relaxation  of  its 
container  takes  place. 

After  foetal  death  the  uterus  itself  becomes  more  plainly 
palpable,  and  there  is  but  Httle  difficulty  in  determining  that 
the  foetus  lies  outside  the  uterus. 

Prognosis. — In  a  general  way  the  prognosis  has  been  given 
in  the  paragraphs  devoted  to  clinical  history  and  diagnosis, 
but  in  a  more  concrete  form  it  may  be  said  that  the  risk  to  Hfe 
is  a  very  distinct  one,  and  that  in  every  instance  the  patient  is 
confronted  by  a  protracted,  painful,  and  dangerous  illness. 
The  risk  of  death  from  the  first  severe  hemorrhage  is  not, 
however,  so  great  as  was  at  one  time  thought,  this  danger 
apparently  being  most  marked  if  the  site  of  rupture  is  in  or  near 
the  uterine  cornua. 

The  late  Dr.  M.  Rosen wasser  of  Cleveland  established  this 
fact  by  a  series  of  clinical  observations  and  published  his 
conclusions  in  the  Transaction  of  the  Ohio  State  Medical  Society 
in  1893.  Since  that  time  other  observers  have  arrived  at  the 
same  conclusion,  both  from  experimental  and  cKnical  observa- 
tion. Unfortunately,  however,  they  have  undertaken  to 
establish  rules  of  treatment  based  on  fallacious  reasoning,  these 
rules  being  more  dangerous  than  those  having  their  origin  in 
the  assumption  that  every  patient  in  profound  shock  from 
ruptured  extra-uterine  pregnancy  is  in  imminent  danger  of 
death. 


39^  EXTRA-UTERINE  PREGNANCY 

TREATMENT 

The  treatment  of  ectopic  pregnancy  in  the  period  pre- 
ceding severe  hemorrhage  from  rupture  or  perforation  is  plainly 
operative.  No  matter  how  much  discussion  may  be  indulged 
in  regarding  the  propriety  of  operation  during  collapse,  be- 
fore that  occurs  there  is  no  possible  ground  for  difference  of 
opinion.  Salpingectomy  should  be  done  precisely  as  in  chronic 
salpingitis,  and  a  smooth  easy  convalescence  is  the  rule.  The 
ovary  can  and  should  be  saved  in  most  cases  which  are  operated 
upon  at  this  time.  Some  discussion,  however,  has  been  pro- 
voked by  the  proposal  to  remove  both  tubes  to  prevent  a  future 
pregnancy  in  the  one  remaining.  The  great  percentage  of 
instances  in  which  this  has  occurred  leads  one  to  look  with 
favor  upon  double  salpingectomy,  providing  there  is  no  objec- 
tion upon  the  part  of  the  patient  and  she  is  in  such  condition  that 
the  added  time  needed  for  removal  of  the  second  tube  will  not 
jeopardize  life. 

Treatment  at  the  Time  of  Rupture. — A  wordy  battle  has 
taken  place  concerning  the  proper  treatment  of  extra-uterine 
pregnancy  at  the  time  of  severe  hemorrhage  and  collapse,  the 
position  of  the  extremists  being  about  as  follows:  One  school 
of  gynaecologists  would  operate  at  once  regardless  of  the  patient's 
condition,  arguing  that  a  large  vessel  is  open  and  that  the 
proper  treatment  for  arterial  hemorrhage  is  a  ligature  about 
the  bleeding  vessel. 

At  the  opposite  extreme  are  a  number  of  surgeons  who  insist 
that  the  lowered  blood  pressure  conduces  to  cessation  of 
hemorrhage,  that  the  bleeding  will  cease  before  death  occurs, 
that  when  the  abdomen  is  opened  at  this  time  the  supposedly 
spurting  vessel  is  never  in  evidence,  that  the  patient  will  rally, 
and  that  so  long  as  she  continues  to  improve  she  should  not  be 
interfered  with  surgically. 

The  importance  of  the  personal  equation  in  establishing  men's 
opinions  should  not  be  lost  sight  of  in  this  controversy,  the  rapid 


TREATMENT  399 

Operators  who  use  simple  technique  almost  invariably  holding 
to  the  former  view,  the  slower  surgeons  with  academic  technique 
the  latter.  Obviously  the  second  class  can  save  more  lives  by 
following  their  conservative  opinions  than  they  could  by  operat- 
ing during  collapse.  A  patient  who  might  die  if  the  abdomen 
were  open  for  an  hour,  will  recover  easily  if  the  operation  re- 
quires but  lo  or  15  minutes. 

The  fallacy  in  both  arguments  lies  in  the  presumption  that 
it  is  the  same  vessel  which  bleeds  at  each  "succeeding  hemor- 
rhage, whereas  it  is  more  than  likely  that  a  new  set  is  opened. 
Experiments  upon  pregnant  cats  and  dogs,  consisting  of  severing 
their  ovarian  arteries,  are  without  weight,  since  the  hemorrhage 
from  an  ovarian  artery  going  to  a  pregnant  uterus  in  no  way 
resembles  the  bleeding  from  a  perforated  or  ruptured  pregnant 
tube. 

The  desirable  method  of  treatment  probably  lies  between  the 
extremes.  The  conservatives  have  taught  us  that  few  die  dur- 
ing the  first  collapse,  the  explanation  lying  in  the  fact  mentioned 
before  .that  this  collapse  is  only  partially  due  to  the  escape  of 
blood  from  the  systemic  circulation,  but  in  equal  degree  is  due 
to  peritoneal  shock  from  rapid  filling  of  the  pelvis  with  blood. 
Should  reaction  not  occur  within  a  few  hours,  however,  it  means 
continued  bleeding,  and  operation  should  be  immediate.  If 
a  rally  follows  the  collapse,  operation  should  be  performed  at  the 
earhest  possible  moment  after  reaction  has  set  in,  for  no  man  can 
say  when  another  hemorrhage  will  occur.  It  is  the  profoundly 
anemic  patient  who  has  had  repeated  hemorrhages  that  suc- 
cumbs to  operation,  not  the  one  in  a  state  of  collapse  from  the 
first  severe  hemorrhage. 

A  good  practical  working  rule  for  the  surgeon  to  follow  if  the 
patient  is  in  collapse,  is  to  operate  as  soon  as  proper  arrangements 
can  be  made  for  operation.  During  the  time  occupied  in  making 
such  preparation,  if  the  collapse  is  not  kept  up  by  continued 
hemorrhage,  the  patient  will  have  rallied;  if  hemorrhage  is  con- 
tinuous, nothing  but  operation  will  save  her.     If  a  competent 


400  EXTRA-UTERINE   PREGNANCY 

rapid  operator  and  proper  facilities  are  not  at  hand,  the  chance 
must  be  taken  that  hemorrhage  will  not  recur  until  such  time 
as  both  can  be  obtained.  Hasty,  imperfect  preparation,  fol- 
lowed by  infection  and  death  from  peritonitis  are  in  no  wise 
better  than  delay  and  death  from  hemorrhage. 

If  circumstances  render  conservative  treatment  necessary,  or 
in  any  event  until  operation  is  performed,  the  treatment  should 
be  that  for  collapse  and  hemorrhage  with  the  vessel  still  bleeding. 
These  measures  are  immediate  lowering  of  the  head  of  the  bed, 
bandaging  the  extremities,  absolute  quiet,  and  the  use  of  mor- 
phine in  such  doses  as  will  relieve  pain  and  restlessness  and  over- 
come apprehension.  The  use  of  saline  solution  subcutaneously, 
intravenously,  or  per  rectum,  is  a  measure  of  questionable  value 
unless  it  immediately  precedes  operation.  When  the  vessel 
is  still  bleeding  saline  infusion  may  cause  death  by  raising  the 
blood  pressure  and  inducing  further  blood  loss.  If  the  bleeding 
has  ceased  it  can  do  no  harm,  but  it  is  absolutely  impossible  to 
determine  this  point  with  any  exactness. 

Strychnine  and  alcoholic  stimulants  may  also  do  harm,  the 
one  by  raising  the  blood  pressure  the  other  by  favoring  vaso- 
dilation. 

Ice-bags  to  the  abdomen  and  heat  to  the  extremities  are  steps 
in  the  right  direction  even  though  their  utility  may  be  somewhat 
doubtful. 

Operation  at  this  time  should  be  done  expeditiously  and 
simply,  but  with  perfect  regard  for  asepsis.  Rapidity  in  operat- 
ing should  be  secured  by  minute  attention  to  all  the  necessary 
arrangement  of  details  before  the  operation  itself  is  begun. 

Two  objects  are  to  be  attained:  the  immediate  control  of 
bleeding,  and  the  removal  of  the  tube  and  ovum.  To  these  ends 
the  patient  is  anaesthetized  with  ether;  chloroform  here  is 
dangerous,  and  nitrous  oxide  rigidity  tends  to  prolong  the  opera- 
tion. It  is  frequently  found  that  the  pulse  improves  as  soon  as 
etherization  is  begun.  The  Trendelenburg  position  favors 
rapidly  in  operating  and  is  of  value  to  the  patient  in  maintaining 


TREATMENT  401 

sufficient  blood  in  the  medulla.  The  abdomen  is  opened 
rapidly,  one  hand  introduced,  and  the  tube  and  ovary  grasped 
and  brought  up  at  once;  clamps  are  placed  at  either  end  of  the 
broad  ligament,  the  tube  cut  away,  and  the  broad  ligament  tied 
beneath  the  clamps  in  one  or  two  sections,  whichever  is 
easier.  The  clamps  are  loosened  and  removed  as  the  Hgatures 
are  tied.  No  attention  is  paid  to  the  intestine  excepting  to 
keep  it  within  the  abdomen,  no  pads  are  placed  and  no  blood 
removed  excepting  as  it  wells  up  and  obscures  the  field.  Ab- 
solutely nothing  more  is  done  at  this  time;  the  other  tube  is  not 
removed,  the  appendix  is  not  sought,  the  abdominal  cavity  is 
neither  sponged  nor  washed.  One  hand  at  the  bottom  of  the 
pelvic  cavity  quickly  removes  any  solid  material  or  clots  of  blood 
which  might  contain  the  ovum,  and  the  abdomen  is  closed  without 
drainage,  sometimes  with  blood  pouring  from  it  at  each  respira- 
tion, but  this  blood  already  is  lost  to  the  patient  and  no  atten- 
tion need  be  paid  to  it.  If  the  condition  is  desperate  through- 
and-through  silkworm  gut  or  silk  sutures  close  the  abdomen.  If 
the  patient  is  in  good  condition  the  usual  method  of  closure  is 
adopted.  The  after-care  is  that  for  the  ordinary  laparatomy 
with  profound  blood  loss;  saline  solution  subcutaneously  or 
plain  water  per  rectum  now  that  further  bleeding  is  not  to  be 
apprehended,  elevation  of  the  foot  of  the  bed,  and  in  extreme 
cases  direct  transfusion  of  blood.  Convalescence  is  rapid  and 
uneventful  excepting  that  the  temperature  usually  rises  rather 
abruptly  and  remains  up  for  several  days. 

Treatment  after  Rupture.— Operations  after  the  death  of  the 
ovum  as  a  rule  are  easy,  even  at  full  term.  Within  the  first 
three  months  they  consist  in  the  removal  of  blood  clot  and 
extirpation  of  the  entire  sac  after  ligation  of  the  broad  ligament. 
Even  if  placenta  has  formed  and  spread  beyond  the  confines 
of  the  tube,  its  removal  after  the  foetus  is  dead  is  not  followed  by 
serious  bleeding,  but  to  deHberately  wait  for  this  is  to  lose 
some  patients  that  might  be  saved  by  earlier  operation. 

The  real  test  of  surgical  judgement  and  abiHty  is  found  in 
26 


402  EXTRA-UTERINE   PREGNANCY 

cases  diagnosed  after  the  end  of  the  third  month  with  the  foetus 
still  alive.  Up  to  the  end  of  five  or  six  months  there  can  be 
little  question  that  operation  is  safer  than  waiting,  but  even 
during  this  period  operation  is  rendered  hazardous  by  the  size 
and  vascularity  of  the  placental  site. 

After  opening  the  abdomen  a  careful  survey  of  the  situation 
should  be  made  with  the  object  of  determining  if  possible  just 
what  vessels  supply  the  site  of  placental  attachment.  Or- 
dinarily it  will  be  found  that  the  ovarian,  and  possibly  the 
uterine,  artery  on  the  pregnant  side  furnish  the  most  of  the  blood 
supply  and  these  are  readily  controlled. 

After  completely  walling  off  the  upper  abdomen  the  ovarian 
artery  is  secured  at  both  ends  of  the  broad  hgament,  the  sac  is 
opened,  the  foetus  removed,  and  the  cord  tied.  This  is  safer 
than  attempting  extirpation  of  the  sac  and  contents  intact  as 
it  gives  better  access  to  the  bottom  of  the  pelvis  whence  severe 
hemorrhage  may  proceed.  The  sac  with  the  placenta  should 
now  be  peeled  from  its  site,  tightly  packed  gauze  replacing  the 
placenta  as  it  is  separated.  After  extirpation  of  the  sac,  bleeding 
areas  should  be  sought  and  controlled  on  general  surgical  prin- 
ciples, always  remembering  the  proximity  of  the  ureter  and  the 
risk  of  narrowing  the  intestine  by  the  insertion  of  too  many 
sutures  in  its  wall.  Very  hot  sponges  and  gauze  tamponade 
usually  control  the  bleeding  sufficiently  to  permit  the  abdomen  to 
be  closed  without  drainage,  but  occasionally  the  necessity  arises 
for  leaving  a  gauze  tampon  applied  to  some  large  oozing  surface. 

Operations  at  this  period  never  should  be  undertaken  by  one 
without  ample  experience  in  surgery.  The  exigencies  of  the 
case  do  not  demand  immediate  interference  and  the  tyro  will 
more  than  likely  lose  his  patient  on  the  table  from  excessive 
blood  loss. 

After  the  fifth  or  sixth  month,  the  foetus  still  Hving,  the  prob- 
lem is  to  decide  whether  to  allow  pregnancy  to  go  beyond  term, 
operating  only  after  the  death  of  the  foetus,  or  to  attempt  to 
secure  a  viable  child. 


treatment:  vaginal  section  403 

Inasmuch  as  the  children  that  attain  full  term  are  so  fre- 
quently deformed  and  defective,  and  the  risk  to  the  mother  is 
so  great,  it  would  seem  the  part  of  wisdom  to  wait  until  the 
child  is  dead.  Operations  during  the  last  two  or  three  months 
of  pregnancy  are  extremely  bloody  if  the  placenta  is  removed 
at  the  time  of  operation,  and  sepsis  supervenes  readily  if 
the  placenta  is  allowed  to  remain. 

A  month  or  so  after  false  labor  the  sac  and  foetus  can  be 
removed  like  any  other  abdominal  tumor,  while  the  placental 
circulation  has  been  so  completely  abolished  as  to  lead  to 
comparatively  little  hemorrhage  when  it  is  detached. 

Vaginal  Section  in  the  Treatment  of  Extra-uterine  Preg- 
nancy.— A  very  skillful  vaginal  operator  may  remove  a  preg- 
nant tube  through  the  vagina,  but  the  average  surgeon  should 
reserve  vaginal  section  for  diagnosis,  in  case  the  differentiation 
between  extra-uterine  pregnancy  and  inflammatory  disease  is 
not  clear,  and  for  the  incision  and  drainage  of  old  haematoceles 
and  pelvic  abscesses  resulting  therefrom. 

Were  it  possible  to  diagnose  rupture  of  the  tube  into  the 
broad  ligament  with  retention  of  blood  between  its  layers,  in- 
cision into  the  broad  ligament  base,  followed  by  gauze  drainage 
through  the  vagina  might  be  practised.  This  diagnosis  could 
rarely  be  made  even  if  it  were  a  common  occurrence,  which  it 
is  not.  It  is  frequently  described,  but  rarely  seen,  the  peri- 
toneum of  the  broad  ligament  undoubtedly  yielding  to  the 
sudden  influx  of  blood  between  its  layers  and  so  allowing  free 
intra-peritoneal  hemorrhage  to  take  place  even  if  the  tube 
ruptures  on  its  inferior  surface. 

REFERENCES 

DOEDERLEIN  AND  HERZOG.— A  New  Type  of  Ectopic  Gestation.  Preg- 
nancy in  an  Adenomyoma  Uteri.     Surg.,  Gyn.  b'  Obst.,  1913,  xvi,  14. 

KOEHLER. — Graviditas  Ovarialis.     Gyn.  Rundschau,  1914,  viii,  275. 

MALL  AND  CUTLER.— An  Ovarian  Pregnancy  Located  in  the  Graffian  Follicle. 
Surg.,  Gyn.  b'  Obst.,  1913,  xvii,  698. 

CZYZEWICZ. — Die  Bauchhohlenschwangerschaft  im  Lichte  neuer  Beobach- 
tungen.     Arch.  f.  Gyn.,  1912,  xcvii,  161. 


404  EXTRA-UTERINE   PREGNANCY 

GRAFENBERG.— Beitriige    zur    Physiologie    der    Eieinbettung.     Zeitsch.    /. 

Geh.  utid  Gyn.,  igio,  Ixv,  i. 
RICHTER. — Die  Primare  Abdominalgraviditat.     Arch.  f.  Gyn.,  191 2,  xcvi. 
BOERMA. — Beitrage  zur   Kenntnis  der  Einbettung  des   Menschlichen   Eies. 

Monats.f.  Geh.  und  Gyn.,  1913,  xxxvii,  723. 
ENGELEIING. — Intraligamentar        entwickelte        Eierstochsschwangerschaft. 

Monats.  f.  Geh.  und  Gyn.,  1913,  xxxvii,  740. 
RUBIN. — A  Case  of  Primary  Ovarian  Pregnancy.     Am.  J,  Ohst.,  191 1,  Ixiii,  814. 
GLAESMER. — Die  interstitielle  Tubargraviditat.     Arch.  f.  Gyn.,  191 1,  xciii, 

100. 
HUFFMAN. — A  Theory  of  the  Cause  of  Ectopic  Pregnancy.     /.  A.  M.  A., 

1913,  Ixi,  2130. 
MEYER. — Die  Entzundung  als  Entstehungsursache  ektopischer  Decidua  oder 

Paradecidua,     Zeitsch.  f.  Geh.  und  Gyn.,  1913,  Ixxiv,  250. 
BECKMANN. — Weiterer  Beitrag  zur  Graviditat  im  rudimentaren  Uterushorn. 

Zeitsch.  f.  Geh.  und  Gyn.,  191 1,  Ixviii,  601. 
HARTZ. — The   Mode  of  Termination  in  Ectopic  Gestation.     Am.  J.  Ohst., 

1 91 5,  Ixxi,  601. 
TANIGUCHI. — Die  Herkunft  der  Blutung  bei  der  Ruptur  der  Tubenschwanger- 

schaft.     Arch.f.  Gyn.,  1914,  cii,  237. 
SCHAUTA. — Ueber    Extrauterinegraviditat.     Wien.     med.    Woch.,    191 1,    Ixi, 

1022. 
MUSSEY. — The  Diagnosis  of  Extra-uterine  Pregnancy.     St.  Paul  M.  J.,  19 14, 

xvi,  588. 
HUGGINS. — Early  Diagnosis  of  Ectopic  Pregnancy.     Trans.  Am.  Assn.  Ohst. 

b"  Gyn.,  191 1,  xxiv,  83. 
SAMPSON. — The  Influence  of  Ectopic  Pregnancy  on  the  Uterus  with  Special 

Reference  to  Changes  in  Its  Blood  Supply  and  Uterine  Bleeding.     Surg., 

Gyn.  6*  Ohst.,  1914,  xviii,  587. 
ROSENWASSER,  M.— Extra-uterine  Pregnancy.     Tr.  Ohio  M.  Soc,  1893,  363; 

Am.  Gyn.  J.,  1893,  412. 
FINDLEY. — Bilateral  Tubal  Pregnancy.     Trans.  Am.  Gyn.  Soc,  1910,  xxxv,  26, 
FEHLING. — Grundsatze   und    Erfahrungen    in   der   Behandlung   der   Tuben- 

schwangerschaft  der  fruhen  Monate.     Arch.  f.  Gyn.,  1910,  xcii,  3. 
SMITH. — Ectopic  Pregnancy,  Final  Results  after  Ten  Years  in  192  Patients 

Operated.     Surg.,  Gyn.  &°  Ohst.,  1914,  xviii,  684. 
COBB. — The  Management  of  the  Grave  Emergency  Cases  of  Extra-uterine 

Pregnancy.     Annals  of  Surg.,  191 2,  Ivi,  835. 
CRAGIN. — The  Treatment  of  Ectopic  Gestation.     Surg.,  Gyn.  &*  Ohst.,   191 2, 

xiv,  276. 
FALK. — Zur  Therapie  der  Extrauteringraviditat.      Arch.f.  Gyn.,  1913,  xcix,  638. 
FALK. — Zur  Behandlung  der  Extrauteringraviditat.     Zeitsch.  f.  Geh.  und  Gyn., 

1913,  Ixxiv,  963. 
OLOW.— tjber  der  Behandlung  der  in  den  friiheren  Monaten  Unterbrochenen 

Extrauterinschwangerschaft.     Monats.f.  Geh.  und  Gyn.,  1914,  xl,  205;  Ahst. 

Inlernat.  Ahst.  Surg.,  Feb.,  191 5. 


REFERENCES  405 

McDonald  and  KRIEGER.~Bilateral  and  Multiple  Ectopic  Pregnancy. 
/.  A.  M.  A.,  1913,  Ix,  1766. 

CONES. — A  Review  of  214  Cases  of  Extra-uterine  Pregnancy  at  the  Massa- 
chusetts Gen.  Hosp.     BosL  M.  &°  S.  J.,  191 1,  clxiv,  677. 

YOUNG. — Emergencies  of  Extra-uterine  Pregnancy.  Bost.  M.  &"  S.  J.,  19 15, 
clxxii,  131. 

LADINSKI.— Treatment  of  Tubal  Pregnancy.     /.  A.  M.  A.,  191 2,  lix,  854. 

SIMPSON. — Deferred  Operation  for  Ruptured  Ectopic  Gestation.  Surg., 
Gyn.  b°  Obst.,  1907,  v,  503. 

BARRETT. — The  Cause  and  Significance  of  Tubal  Rupture  in  Extra-uterine 
Pregnancy.     Am.  J.  Obst.,  191 1,  Ixiii,  975. 

JACOBSOHN. — Die  vaginale  Koliotomie  bei  ektopischen  Schwangerschaft. 
Monats.  f.  Geb.  und  Gyn.,  1910,  xxxii;  Ergangzungsheft,  i. 


CHAPTER  XIII 

DISEASES  OF  THE  OVARIES 

Acute  Oophoritis,  Etiology. — Acute  inflammation  of  the 
ovaries  may  be  either  septic  or  gonorrheal  in  origin.  Septic 
oophoritis  frequently  results  from  infection  of  the  uterus 
following  abortion,  full-term  labor,  or  the  use  of  unclean  instru- 
ments. It  may  arise  also  from  direct  contact  with  virulent 
pus  which  has  gravitated  to  the  bottom  of  the  pelvis  during  an 
attack  of  septic  peritonitis  from  any  source.  The  relation  of 
septic  oophoritis  to  infection  of  the  cervix  and  body  of  the 
uterus  is  explained  by  their  lymphatic  connections,  and  is 
somewhat  analogous,  although  not  entirely  parallel,  to  second- 
ary involvement  of  the  axillary  lymph  glands  from  an  in- 
fected wound  of  the  hand,  the  lymphatics  in  the  broad  liga- 
ment readily  conveying  micro-organisms  from  the  uterus  to 
the  hilum  of  the  ovary.  Specific  oophoritis  is  the  result  of  the 
outpouring  of  irritating  gonorrheal  pus  from  the  fimbriated 
end  of  the  tube  onto  the  surface  of  the  ovary,  and  it  is  always 
secondary  to  specific  salpingitis. 

Clinical  Course  and  Prognosis. — The  clinical  course  of  specific 
infection  of  the  ovary  is  dependent  upon  its  tubal  origin 
and  does  not  require  separate  consideration.  The  clinical 
course  of  septic  oophoritis  depends  upon  the  character  and  viru- 
lence of  the  micro-organisms  present.  If  the  infection  is  mild 
and  confined  to  the  ovary,  the  clinical  course  is  that  of  a  very 
moderate  localized  pelvic  inflammation  and  complete  resolution 
may  take  place.  Should  an  abscess  form  and  be  confined  to 
the  interior  of  the  ovary,  the  end  result  may  be  an  enlarged 
cystic  ovary  containing  a  thin  serous  fluid  or  inspissated  pus. 
If  the  abscess  ruptures  before  its  contents  become  sterile,  the 

406 


ACUTE   OOPHORITIS  407 

immediate  result  is  an  acute  peritonitis  which  usually  remains 
locahzed,  but  occasionally  is  of  the  spreading  virulent  variety. 
When  peritonitis  occurs  peritoneal  serum  is  poured  into  the 
pelvic  cavity  in  large  quantities,  and  if  the  infection  is  not  too 
virulent  this  serum  soon  solidifies  and  forms  a  rampart  of  ad- 
hesions about  the  affected  area.  The  products  of  suppuration 
tend  to  gravitate  to  the  bottom  of  the  pelvic  cavity  and  in  this 
way  produce  the  well-known  pelvic  abscess,  which,  in  favorable 
cases,  will  point  in  the  direction  of  the  posterior  vaginal  fornix. 
Such  an  abscess,  however,  may  rupture  into  the  bowel  or 
bladder,  or  burrow  through  the  surrounding  adhesions  into 
the  general  peritoneal  cavity.  Rupture  into  the  vagina  or 
bowel  usually  leads  to  spontaneous  cure  of  the  acute  infection, 
but  there  remains  an  adherent  enlarged  ovary  as  in  the  milder 
infections  without  rupture  of  the  abscess.  After  a  time  the 
contents  of  these  cystic  ovaries  become  sterile,  but  notwith- 
standing their  sterility  complete  resolution  does  not  occur  if 
the  infection  has  been  virulent  enough  to  produce  an  ovarian 
abscess.  Rupture  of  a  pelvic  abscess  through  the  surrounding 
adhesions  into  the  general  peritoneal  cavity  may  be  rapidly 
fatal. 

Symptoms  and  Diagnosis. — If  a  correct  history  can  be  ob- 
tained, it  is  that  of  abortion,  labor,  or  the  introduction  of  in- 
struments into  the  uterus,  followed  in  a  short  time  by  the  onset 
of  pain  on  one  side  of  the  pelvis.  If  the  infection  is  so  over- 
whelming that  the  ovarian  inflammation  plays  but  a  small  part 
in  a  generalized  process,  the  local  symptoms  may  be  unimportant 
and  the  diagnosis  impossible.  Nausea  and  vomiting  may  take 
place  as  they  do  in  most  abdominal  infections  with  peritoneal 
involvement,  and  both  the  pulse  and  temperature  are  elevated. 
An  increased  leucocyte  count  is  to  be  expected  in  every  case 
in  which  the  process  is  not  so  severe  as  to  overwhelm  the  resist- 
ing power  of  the  body,  and  an  increase  in  the  relative  propor- 
tion of  polymorphonuclear  leucocytes  is  of  both  diagnostic 
and  prognostic  importance.     As  the  result  of  a  general  pelvic 


4o8  DISEASES  OF  THE  OVARIES 

congestion,  which  is  incidental  to  the  inflammatory  process, 
there  is  an  incraesed  prolonged  menstrual  discharge  should  the 
patient  be  flowing  at  the  time  of  onset,  and  moderate  inter- 
menstrual bleeding  may  be  caused  in  the  same  manner.  On 
examining  the  abdomen  there  usually  is  some  tympany, 
superficial  tenderness  to  pressure  on  the  affected  side,  and 
more  or  less  protective  rigidity  of  the  abdominal  muscles  over 
the  pelvis,  although  this  rigidity  is  not  so  marked  as  in  peri- 
tonitis about  the  appendix,  gall-bladder,  or  stomach.  Dullness 
on  percussion  is  absent  early  in  the  disease,  but  later  it  is 
sometimes  found  over  large  exudates. 

Vaginal  examination  shows  increased  resistance  of  a  very 
indefinite  character  together  with  extreme  tenderness  lateral 
to  the  uterus,  and  during  the  first  few  hours  this  may  be  the 
only  evidence  of  disease  which  the  finger  can  elicit.  After  two 
or  three  days  peritoneal  exudate  in  the  recto-uterine  excavation 
will  be  felt,  and  if  the  patient  is  not  too  sensitive,  a  mass  can  be 
made  out  at  one  side  of  the  uterus  on  bi-manual  examination. 
So  far  the  local  signs  do  not  differ  from  those  of  specific  sal- 
pingitis, excepting  that  the  swelling  is  more  likely  to  be  limited  to 
one  side  in  septic  oophoritis.  Within  a  few  days  there  is  likely 
to  be  some  remission  in  the  symptoms,  which  may  or  may  not  be 
followed  by  a  sudden  and  marked  increase  in  their  severity. 
This  remission  is  explained  by  the  walling  in  of  the  infected  area 
about  the  ovary,  and  the  sudden  increase  in  symptoms  by  the 
rupture  of  adhesions  or  the  cortex  of  the  ovary  itself,  thus  per- 
mitting infectious  material  to  escape  into  unprotected  portions 
of  the  pelvic  cavity.  Should  the  disease  progress  to  the  stage 
of  pelvic  abscess,  marked  bulging  will  be  found  in  the  recto- 
uterine excavation,  and  in  late  cases  this  extends  almost  to  the 
vaginal  outlet,  while  at  a  comparatively  early  stage  in  the  forma- 
tion, of  pus  an  area  of  softening  may  be  felt  posterior  to  the 
cervix.  The  symptoms  are  exaggerated  and  the  physical  signs 
modified  if  the  infection  takes  place  after  full-term  labor  ow- 
ing to  the  location  of  the  ovary  above  the  pelvic  inlet  at  this 


ACUTE   OOPHORITIS  409 

time,  and  inflammatory  products  which  escape  from  its  interior 
are  more  likely  to  cause  general  peritonitis.  The  rapidity  with 
which  absorption  takes  place  through  the  peritoneum  of  the 
upper  abdomen,  as  compared  to  the  slow  absorption  through  the 
pelvic  peritoneum,  tends  also  to  render  the  symptoms  more 
violent.  Should  virulent  peritonitis  not  make  its  appearance, 
the  exudate  which  forms  is  above  the  pelvic  inlet  and  the  ovary 
consequently  becomes  fixed  much  higher  in  the  abdomen  than 
it  would  if  the  uterus  were  normal  in  size.  Indeed,  it  is  not  un- 
usual to  find  the  ovary  adherent  to  the  sigmoid  on  the  left,  to 
the  caecum  on  the  right,  or  to  the  anterior  abdominal  wall  on 
either  side. 

Acute  septic  oophoritis  must  be  differentiated  from  appendi- 
citis, ectopic  pregnancy,  and  specific  salpingitis.  In  making  this 
differentiation  an  accurate  history  is  of  the  first  importance, 
and  errors  in  diagnosis  are  inevitable  if  this  cannot  be  obtained 
or  is  wilfully  misleading.  In  acute  appendicitis,  epigastric 
pain,  almost  without  exception,  is  the  first  indication  of  ab- 
dominal trouble,  and  is  followed  in  a  very  short  time  by  vomit- 
ing and  fever,  in  the  order  stated.  Shortly  after  the  onset  of 
epigastric  pain,  and  coincident  with  the  occurrence  of  peritonitis 
about  the  ruptured  appendix,  pain  makes  its  appearance  in  the 
right  ihac  fossa  or  in  the  pelvis,  but  pain  which  was  noticed 
first  in  the  epigastrium,  or  elsewhere  above  the  umbihcus,  is 
so  distinctly  appendicular  rather  than  pelvic  in  origin  that  the 
location  of  the  earliest  pain  should  be  given  great  weight  in 
diagnosis. 

In  specific  salpingitis,  which  is  so  severe  as  to  simulate  septic 
oophoritis,  a  history  of  gonorrheal  infection  is  almost  always 
obtainable,  a  yellow  leucorrheal  discharge  and  bladder  irri- 
tabihty  following  soon  after  marriage  or  suspicious  intercourse. 
At  this  stage  gonococci  are  usually  demonstrable  in  the  dis- 
charge from  the  cervix  and  urethra,  and  in  addition,  the  fact 
that  the  pelvic  infection  is  bilateral  in  salpingitis  assists  in 
differentiating  it  from  acute  oophoritis.    Trivial  intra-abdominal 


4IO  DISEASES    OF   THE    OVARIES 

hemorrhage  from  an  early  extra-uterine  pregnancy  may  give 
rise  to  all  of  the  symptoms  of  a  mild  acute  oophoritis.  Inter- 
menstrual bleeding  is  likely  to  occur  in  both,  and  irregular 
menstruation  is  likewise  common  to  both.  The  elevation  of 
temperature  following  a  slight  hemorrhage  into  the  abdomen  is 
usually  not  so  high  as  the  elevation  in  acute  oophoritis.  Pro- 
tective spasm  of  the  abdominal  muscles,  tenderness  to  external 
pressure,  tenderness  upon  bi-manual  examination,  and  a  mass  in 
the  pelvis  are  Hkewise  found  in  both  diseases.  One  symptom 
that  points  to  ectopic  pregnancy  rather  than  ovarian  inflamma- 
tion is  the  line  of  tympany  which  frequently  makes  its  appear- 
ance above  the  effused  blood.  Profound  shock  and  collapse  at 
some  time  during  the  course  of  the  illness  is  more  common 
in  extra-uterine  pregnancy  than  in  any  other  pelvic  condition, 
as  is  the  subsequent  extreme  degree  of  anaemia,  neither  of 
which  are  seen  in  acute  oophoritis.  A  history  of  attempted 
abortion  does  not  always  clear  up  the  diagnosis,  as  many 
patients  who  are  the  victims  of  ectopic  pregnancy  believe  them- 
selves to  be  normally  pregnant  and  introduce  instruments  into 
the  uterus  with  the  intention  of  inducing  abortion.  The  sensa- 
tion conveyed  to  the  finger  by  exudate  about  an  inflammatory 
focus  differs  from  that  produced  by  effused  blood,  because  peri- 
toneal exudate  solidifies,  while  blood  undergoes  clotting  only, 
and  the  consistency  of  each  is  quite  characteristic. 

A  mistake  in  diagnosis  as  between  specific  salpingitis  and 
septic  oophoritis  is  almost  unavoidable  in  those  rare  cases  in 
which  gonorrhea  has  remained  latent  in  the  cervix  or  about  the 
vulva  during  pregnancy,  only  to  become  acute  and  extend  to 
the  body  of  the  uterus  and  thence  to  the  tubes  soon  after 
abortion  or  labor. 

Treatment. — In  an  individual  case  an  error  in  diagnosis  may 
do  no  harm,  but  on  the  whole  the  correct  treatment  of  acute 
ovarian  infection  is  dependent  upon  a  correct  diagnosis.  The 
treatment  of  acute  appendicitis  and  the  treatment  of  ectopic 
pregnancy  are  essentially  the  same,  operation  upon  diagnosis, 


TREATMENT   OF   ACUTE    OOPHORITIS  41I 

while  that  of  acute  oophoritis  is  dependent  upon  the  extent  of  the 
pathological  change  and  not  upon  the  fact  that  an  infection  of 
the  ovary  exists.  Palliative  treatment  should  be  practised  in 
those  mild  cases  in  which  the  infection  is  confined  to  the  ovary, 
with  possibly  a  trivial  local  peritonitis  and  small  amount  of 
exudate,  absolute  rest  in  bed  being  the  most  important  con- 
sideration. For  the  relief  of  pain  ice-bags  over  the  pelvis, 
or  counterirritation  followed  by  the  application  of  moist  heat 
are  usually  sufficient,  the  choice  between  heat  and  cold  being 
somewhat  dependent  upon  the  sensations  of  the  patient. 
There  is  no  objection  to  the  use  of  narcotics  in  small  doses  if 
they  are  necessary  to  make  the  patient  comfortable,  providing 
always  that  they  are  not  continued  beyond  the  acute  stage  of  the 
disease,  and  their  constipating  effect  is  overcome  by  means  of 
enemas.  Cathartics  do  no  harm  if  the  infection  happens  to 
be  confined  to  the  interior  of  the  ovary  but  are  productive  of 
damage  when  peritonitis  is  present.  The  bowels  of  course 
are  to  be  kept  open,  but  this  should  be  accomplished  by  enemas 
instead  of  drugs,  the  routine  dose  of  calomel  and  salts,  so  fre- 
quently given  at  the  outset  of  any  intra-abdominal  infection, 
being  fraught  with  great  danger.  Local  applications  to  the 
vagina  in  the  form  of  tampons,  douches,  etc.,  should  be  avoided 
during  the  acute  stage  as  they  do  no  good  and  seriously  inter- 
fere with  the  first  desideratum  which  is  perfect  rest. 

Acute  oophoritis  of  a  severe  type,  in  which  fluid  appears  in 
the  recto-uterine  excavation  at  an  early  date,  should  be  treated 
by  vaginal  incision  and  drainage,  as  by  so  doing  the  extension 
of  infection  to  the  upper  portion  of  the  abdominal  cavity  can 
be  prevented  in  most  instances.  While  drainage  of  the  cul-de-sac 
only  may  be  sufl&cient,  it  is  wiser  to  make  a  distinct  operation 
of  this  simple  procedure  so  that  the  ovary  can  be  palpated  by 
a  finger  introduced  through  the  incision.  When  the  ovary  is 
found  to  be  enlarged  and  fluctuating,  it  should  be  perforated  to 
permit  drainage  of  the  primary  focus  in  its  interior. 

The  influence  of  the  sitting  or  semi-sitting  position  in  causing 


412  DISEASES   OF  THE  OVARIES 

septic  peritoneal  fluids  to  gravitate  to  the  bottom  of  the  pelvis 
may  possibly  be  open  to  question  when  the  abdominal  cavity 
is  closed.  There  is  no  doubt  of  its  advantage,  however,  when 
an  opening  exists  in  the  most  dependent  portion,  and  patients 
with  pelvic  peritonitis  should  be  placed  in  this  position  for  the 
first  day  or  two  after  operation  if  the  condition  of  the  heart 
permits.  The  rapid  formation  of  adhesions  about  the  infected 
area  and  about  the  drainage  material  makes  it  unnecessary  to 
continue  the  sitting  posture  for  more  than  48  hours. 

In  cases  midway  in  severity  between  the  two  just  mentioned, 
that  is,  those  in  which  considerable  exudate  forms  but  the  patient 
is  not  desperately  ill,  interference  should  not  be  practised  during 
the  acute  stage  unless  a  point  of  softening  makes  its  appearance 
in  the  mass  of  hard  exudate  which  is  palpable  through  the 
vaginal  fornix.  Such  cases  translate  themselves  into  pelvic 
abscesses  and  should  be  treated  as  such. 

After  labor  at  term  the  high  location  of  the  ovaries  makes  it  im- 
possible to  reach  them  through  an  opening  in  the  vagina,  so  that 
when  drainage  is  necessary  the  incision  must  be  made  through 
the  anterior  abdominal  wall  and  over  the  area  of  induration. 
Any  evidence  of  rupture  of  the  infected  ovary,  or  a  serious 
degree  of  peritonitis,  should  be  met  by  prompt  laparotomy, 
because  involvement  of  the  abdominal  peritoneum  is  so  much 
more  serious  than  that  of  the  pelvic,  and  adhesions  about  the 
infected  area  are  less  likely  to  form  before  serious  damage  has 
occurred.  It  is  in  cases  of  this  kind  that  an  ovary  sometimes 
must  be  removed,  although  thorough  walling  off  of  the  healthy 
peritoneum  and  adequate  drainage  of  the  ovary  itself  frequently 
results  in  complete  recovery  so  far  as  the  acute  infection  is 
concerned.  Even  after  bilateral  involvement  complete  resolu- 
tion is  possible  and  may  be  followed  by  subsequent  pregnancy, 
but  such  is  not  the  usual  outcome.  On  the  contrary,  an  enlarged 
cystic  ovary  usually  remains,  and,  although  the  infection  has 
so  far  disappeared  that  the  patient's  life  no  longer  is  in  dan- 
ger, the  constant  pain  leads  her  ultimately  to  undergo  removal 


PROLAPSE   OF   OVARY 


413 


of  the  organ  rather  than  be  made  a  semi-invalid  by  the  pelvic 
discomfort. 

Prolapse  of  the  Ovary.- — The  term  ''prolapse  of  the  ovary" 
impHes  that  the  organ  has  fallen  below  its  normal  level  in  the 
pelvic  cavity.  The  cause  may  be  increased  size  and  weight  of 
the  ovary,  relaxation  of  the  Hgaments  which  normally  support 
it,  or  a  posterior  displacement  of  the  uterus  which  carries  the 
ovary  with  it.  It  is  not  certain  that  prolapse  per  se  is  pro- 
ductive of  any  symptoms,  but  it  is  true  clinically  that  most 


Fig.  209. — Both  ovaries  prolapsed  to  bottom  of  recto-uterine  excavation. 


patients  with  a  marked  degree  of  ovarian  prolapse  have  symp- 
toms which,  either  directly  or  indirectly,  are  referable  to  the 
displacement.  When  the  ovary  falls  to  the  bottom'  of  the 
recto-uterine  excavation  the  irritation  of  hard  fecal  masses, 
injury  during  coitus,  and  the  pressure  of  a  displaced  uterus 
are  all  productive  of  pain.  An  inflamed  prolapsed  ovary  gives 
rise  to  an  extraordinary  amount  of  pain  which  may  be  referable 
partly  to  its  location  and  partly  to  the  inflammatory  condition. 
Should  the  ovary  become  adherent  in  its  abnormal  location  the 
above-mentioned  traumatic  influences  are  productive  of  more 


414  DISEASES   OF   THE   OVARIES 

severe  symptoms  than  they  are  when  the  ovary  is  so  freely  mov- 
able that  it  slips  away  from  any  direct  pressure  which  may  be 
apphed  to  it.  The  diagnosis  is  easy.  On  bi-manual  examina- 
tion one  or  both  ovaries  are  found  to  be  absent  from  the  normal 
location,  while  a  body  or  bodies  corresponding  to  the  size  and 
shape  of  the  ovary  are  found  in  the  cul-de-sac,  and  these 
almost  without  exception  are  hypersensitive  to  pressure.  If 
not  fixed  by  adhesions,  a  prolapsed  ovary  may  be  readily  re- 
turned to  its  normal  location  but  immediately  drops  back  to 
its  former  position.  Pressure  upon  a  prolapsed  hypersensi- 
tive ovary  produces  nausea  and  a  peculiar  sickening  sensation 
similar  to  that  caused  by  pressure  upon  the  male  testicle. 
When  a  prolapsed  ovary  is  adherent  it  may  be  impossible  to 
map  it  out  as  a  single  organ,  but  under  these  circumstances  its 
position  is  of  Httle  importance  compared  to  the  inflammatory 
process  by  which  it  became  fixed  in  its  abnormal  location. 

Treatment. — While  prolapse  of  the  ovary  may  not  per  se 
require  any  treatment,  prolapse  combined  with  the  diseases 
with  which  it  usually  is  associated  needs  some  form  of 
intervention. 

If  prolapse  of  the  ovary  co-exists  with  retrodisplacement 
of  the  uterus,  the  return  of  the  latter  to  its  normal  position 
followed  by  the  mechanical  support  of  a  pessary  may  be  all 
that  is  necessary.  Often,  however,  the  ovaries  remain  in  their 
abnormal  position  when  the  uterus  is  replaced  and  the  pessary 
is  not  well  borne  because  its  posterior  bar  impinges  upon  them. 
In  this  event  even  a  freely  movable  uterus  may  require  opera- 
tion, and  when  such  is  the  case,  the  mal-position  of  the  ovary 
should  be  corrected  by  shortening  the  infundibulo-pelvic  Hga- 
ment  or  attaching  the  ovary  to  the  horn  of  the  uterus  by  the 
utero-ovarian  ligament,  either  of  which  will  suffice  to  retain  it 
in  its  normal  position.  A  prolapsed  adherent  ovary  does  not 
necessarily  need  removal.  Unless  it  is  markedly  enlarged  and 
cystic,  its  release  from  the  surrounding  adhesions  and  attach- 
ment higher  up  in  the  pelvic  cavity  by  one  of  the  above  methods 


TUMORS   OF   THE   OVARY  415 

renders  excision  unnecessary.  In  elective  operations  of  this 
kind,  that  which  shall  be  done  with  one  ovary  is  often  con- 
tingent upon  the  condition  of  the  other.  If  one  ovary  is 
perfectly  healthy,  the  sacrifice  of  the  other  is  no  hardship  to 
the  patient;  if  both  are  in  questionable  condition,  every  possible 
effort  should  be  made  to  conserve  the  better  of  the  two. 

OVARIAN  TUMORS 

Tumors  of  the  ovary  frequently  are  classified  as  benign  and 
malignant,  but  the  dividing  line  often  is  too  indefinite  to  permit 
such  classification.  They  are  also  classified  as  solid  and  cystic, 
but  again  this  is  by  no  means  accurate.  The  best  classification 
is  that  proposed  by  Pfannenstiel  into  stromatogenous  and  par- 
en  chym  a  togenous  tumors.  Tumors  arising  from  the  stroma 
are  fibromata  and  sarcomata.  Those  arising  from  the  paren- 
chyma take  their  origin  either  from  the  germinal  epithelium  or 
from  the  vesicular  ovarian  follicles.  The  parenchymatous 
tumors  are  retention  cysts,  corpus  luteum  cysts,  dermoids, 
papillomata,  cyst-adenomata,  and  carcinomata.  Nearly  a  third 
of  the  cystic  pelvic  tumors,  which  are  loosely  called  ovarian 
cysts,  arise  from  the  epo-oophoron  and  really  are  parovarian 
cysts.  The  ultimate  etiology  is  not  known,  but  all  ovarian 
tumors  are  said  to  be  more  common  in  child-bearing  women. 
The  carcinomata  are  largely  due  to  degenerative  processes  in 
other  ovarian  tumors,  or  else  are  secondary  to  carcinomatous 
growths  elsewhere  in  the  abdominal  cavity. 

Pathology. — The  pathology  of  the  fibromata  and  sarcomata 
does  not  differ  from  that  of  similar  growths  elsewhere.  Unlike 
fibroma  and  sarcoma,  and  unlike  carcinoma  in  general,  carcino- 
matous tumors  of  the  ovary  are  sometimes  cystic,  the  fluid  ap- 
parently being  produced  by  the  activity  of  the  secreting  epi- 
thelium composing  the  greater  part  of  the  malignant  growth. 
Retention  cysts  usually  are  small  in  size,  and  while  it  is  true  that 
the  etiology  of  most  ovarian  growths  is  unknown,  this  state- 


4i6 


DISEASES   OF   THE   OVARIES 


ment  should  be  modified  in  the  case  of  retention  cysts  to  the  ex- 
tent of  saying  that  in  all  probability  they  are  due  to  thickening 
of  the  tunica  albuginea.  The  cyst  wall  about  the  ovarian  foUicle 
therefore  fails  to  rupture,  while  the  epitheUum  which  Knes  the 
follicle  continues  to  secrete  fluid  until  such  time  as  the  pressure 
of  the  fluid  within  produces  pressure  atrophy  of  the  epithelial 
lining,  when  the  cyst  ceases  to  grow.     This  form  of  tumor  is 


--Wv.-- 


Fig.  2IO. — Simple  cyst  of  the  ovary,  retention  cyst,  cystic  follicle. 

comparatively  frequent  as  a  sequel  of  acute  oophoritis.  Corpus 
luteum  cysts  also  form  in  consequence  of  the  failure  of  the  corpus 
luteum  to  pursue  its  ordinary  physiological  course,  while  the 
secretion  of  fluid  continues  in  its  interior.  Corpus  luteum  cysts 
are  small  in  size  and  frequently  have  a  layer  of  lutein  cells  as 
their  innermost  lining. 

Ovarian  dermoids  are  the  most  interesting  tumors  in  the  body. 
In  their  simpler  forms  they,  like  dermoids  elsewhere,  appear  to 


PATHOLOGY    OF   TUMORS    OF   THE    OVARY  417 

be  due  to  inversion  and  proliferation  of  the  epiblastic  cells,  which 
are  principally  epithelial,  but  many  ovarian  dermoids  are  more 
complicated  in  their  structure  and  contain  tissues  derived  from 
all  three  of  the  primitive  embryonic  layers.  At  present  the 
consensus  of  opinion  seems  to  be  that  all  ovarian  dermoids  are 
parenchymatous,  and  that  they  originate  in  some  direct  manner 
from  the  ovules.  These  tumors  rarely  are  excessive  in  size 
and  occasionally  are  bilateral.  They  are  semi-fluctuating  when 
in  situ,  but  after  removal  they  become  firmer  from  the  harden- 
ing of  their  sebaceous  contents  under  the  influence  of  the  lower 
temperature  outside  the  body.  Their  contents  consist  of  se- 
baceous material,  hair,  teeth,  and,  in  the  parenchymatous  form, 
portions  of  other  tissues  and  even  organs.  The  hair  is  found 
in  the  form  of  a  ball  or  switch  in  some  tumors,  and  in  others 
as  a  short  stubbly  growth.  Careful  examination  of  cyst-adeno- 
mata reveals  the  fact  that  many  of  them  contain  a  small  der- 
moid. The  fluid  and  sebaceous  contents  of  a  dermoid  are 
formed  from  the  epithelium  which  lines  its  interior.  The  cyst 
wall  usually  is  quite  thin  and  is  largely  made  up  of  connective 
tissue,  the  outer  covering  of  the  tumor  being  that  of  the  ovary 
itself. 

Papillomata,  in  addition  to  the  ordinary  structures  which  make 
up  an  ovarian  cyst,  contain  warty  or  fijiger-like  excrescences 
growing  into  their  interiors.  They  are  usually  unilocular  and 
contain  serous  fluid  into  which  project  the  irregular  masses  of 
papillomatous  outgrowth.  So  long  as  these  projections  are 
inward  only  the  tumors  may  be  considered  as  cHnically  benign, 
but  unfortunately  they  sometimes  erode  through  the  tumor,  or 
grow  into  the  abdominal  cavity  from  the  external  tumor  wall, 
whence  by  constant  proliferation  they  become  attached  to  other 
organs.  When  this  occurs  they  are  clearly  malignant,  and  their 
removal  is  almost  certain  to  be  followed  by  recurrence.  The 
papillomatous  excrescences  are  composed  of  a  stroma  of  connect- 
ive tissue  which  contains  blood-vessels,  and  they  are  covered 
on  their  outer  surface  by  epithelium  of  the  columnar  variety. 
27 


4i8 


DISEASES   OF   THE   OVARIES 


All  the  foregoing  varieties  of  ovarian  tumor  are  met  with 
from  time  to  time,  but  they  are  relatively  infrequent  as  com- 
pared to  the  cyst-adenoma  which  is  the  common  type  of  ovarian 
cyst. 

Cyst-adenomata  usually  are  globular  in  form  although  the 


Fig.  211. — Papilliferouscyst-adeno-carcinoma.  Developing  in  a  papillifcrous 
cyst-adenoma  of  theovary.  In  the  upper  central  part  of  the  field  are  to  be  seen 
many  papuliferous  epithelial  outgrowths  from  the  wall  of  a  cyst  without  much 
infiltration  of  the  basement  membrane  surrounding  this  cyst  wall,  but  at  the 
right  the  epithelial  cells  are  broken  up  into^numerous  small  groups  infiltrating 
the  stroma.  Here  the^basement  membrane  of  one  of  the  cysts  has  been  broken 
through  and  the  epithelial  cells  are 'growing  atypically  throughout  the  stroma. 
This  tumor  showed  a  very  definite  change  to  the  adeno-carcinoma  type. 

rapid  growth  of  adenomatous  masses  may  render  their  exterior 
somewhat  knobbed,  like  uterine  fibroids.  The  older  portion 
of  the  cyst  is  distinctly  fluctuating  unless  its  wall  is  very  tense, 
while  the  newer  portion  may  be  quite  firm  in  consistency.  The 
exterior  is  usually  a  Hght  bluish  gray  in  color.     The  cyst  wall 


PATHOLOGY   OF   TUMORS    OF   THE    OVARY 


419 


is  composed  of  connective  tissue  which  is  covered  externally  by 
the  epithelial  covering  of  the  ovary  proper,  and  internally  by 
the  secreting  epithehal  cells  whose  activities  produce  the  fluid 
contents.  Cyst-adenomata  with  but  few  exceptions  are  multi- 
locular,  and  while  pressure  atrophy  occasionally  may  cause  the 
walls  between  the  locules  to  undergo  degeneration  and  finally 


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Fig.  212. — Multilocular  cyst  adenoma  simplex  of  the  ovary.  The  micro- 
photograph  shows  the  pale  simple  columnar  epithelium 'with  its  tall  cells,  the 
strands  of  tissue  made  up  of  ovarian  stroma  and  proliferating  connective  tissue, 
and  the  granular,  stringy  pseudo-mucin  filling  the  cystic  spaces. 


rupture,  evidences  of  such  subdivision  usually  can  be  found. 
The  contents  of  cyst-adenomata  vary  in  color,  and  one  may  see 
a  single  tumor  one  of  whose  locules  contains  almost  colorless 
fluid,  another  yellow,  and  another  dark  brown  or  chocolate- 
colored  material.  The  variations  in  color  depend  somewhat 
upon  the  quantity  of  fluid  but  more  upon  the  presence  or  absence 


420  DISEASES   OF   THE  OVARIES 

of  blood.  Most  cyst-adenomata  contain  quantities  of  mucin 
which  gives  a  gelatinous  appearance  to  their  contents. 

A  cyst-adenoma  is  a  proliferating  tumor,  and  the  formation 
of  fluid  in  its  interior  does  not  cause  sufficient  pressure  on  its 
walls  to  check  the  secretion  of  those  cells  which  are  responsible 
for  the  continued  increase  in  its  contents.  It  therefore  grows 
indefinitely  and  ultimately  attains  an  enormous  size. 

The  pedicle  of  a  true  ovarian  tumor  is  composed  of  the 
drawn-out  broad  ligament,  the  utero-ovarian  ligament,  the  in- 
fundibulo-pelvic  ligament,  and  usually  a  portion  of  the  tube, 
together  with  those  blood-vessels  and  lymphatics  which  enter 
the  hilum  of  the  ovary.  The  pedicle,  therefore,  is  covered  by 
peritoneum,  while  the  tumor  itself  is  covered  -only  by  the  epi- 
thehal  coat  of  the  ovary  which  is  not  peritoneal  in  character. 
Occasionally  a  true  ovarian  cyst  is  found  whose  expansion 
carries  it  toward  the  broad  ligament  rather  than  into  the  peri- 
toneal cavity.  While  such  a  tumor  is  never  completely  in- 
vested by  peritoneum,  that  portion  of  it  which  has  grown  in 
immediate  proximity  to  the  hilum  of  the  ovary  may  be,  be- 
cause of  its  having  pushed  between  and  spread  out  the  layers 
of  the  broad  ligament  over  the  ovarian  attachment  at  the 
hilum. 

The  nature  of  their  outer  coat  serves  to  distinguish  the 
true  ovarian  cysts  from  parovarian  cysts.  Parovarian  cysts 
originate  from  the  epo-oophoron  (parovarium)  in  the  broad 
Hgament,  and  primarily  are  retention  cysts  of  Kobelt's  tubules. 
They  are  contained  .'between  the  folds  of  the  broad  ligament 
and  thus  are  covered  by  peritoneum.  As  retention  cysts  only, 
they  are  small  in  size,  but  overactivity  of  the  epithelial  lining 
of  the  tubules  may  be  productive  of  a  large  thin-walled  sessile 
growth.  The  tube  is  drawn  over  the  top  of  a  parovarian  cyst, 
while  its  base  extends  to  the  base  of  the  broad  ligament  from 
which  its  blood  supply  is  derived. 

The  wall  of  a  parovarian  cyst  is  thin,  and  is  composed  of  con- 
nective tissue   covered  externally   by  the  peritoneum  of  the 


ACCIDENTS   TO   TUMORS    OF   THE   OVARY  42 1 

broad  ligament  and  internally  by  the  secreting  epithelium  from 
which  its  serous  contents  are  derived. 

Clinical  Course  and  Prognosis  of  Ovarian  Tumors. — The 
sarcomata  and  carcinomata  behave  here  as  elsewhere  in  the 
abdominal  cavity.  They  grow  rapidly,  extend  to  other  organs 
at  an  early  date,  produce  ascites,  and  give  rise  to  metastases. 
A  partial  exception  to  the  rule  of  early  extension  may  be  found 
in  those  carcinomata  which  are  secondary  to  other  ovarian 
tumors,  and  whose  early  extension  is  delayed  by  the  fact  that 
they  grow  within  the  interior  of  the  tumor  and  thus  remain 
encapsulated  for  a  considerable  time.  Untreated  carcinomata 
and  sarcomata  invariably  are  fatal. 

Dermoids  may  be  found  at  any  age.  They  grow  slowly  and 
rarely  attain  great  size  but  are  subject  to  the  accidents  which 
are  detailed  elsewhere.  Serous  cysts  of  any  size  may  rupture, 
either  spontaneously  or  through  the  medium  of  some  trivial 
accident,  and  such  rupture  is  without  serious  consequence 
unless  the  tumor  is  a  cyst-adenoma  or  papilloma,  when  im- 
plantation metastases  may  occur.  Spontaneous  or  accidental 
rupture  does  not  lead  to  cure  as  the  cyst  contents  rapidly  re-ac- 
cumulate. Cyst-adenomata  progress  indefinitely,  attain  a  huge 
size,  and  if  not  removed  are  almost  as  surely  fatal  as  true 
mahgnant  growths. 

Papillary  tumors  stand  midway  between  malignant  and  benign 
growths.  Should  the  papillomatous  masses  remain  confined  to 
the  interior  of  the  tumor,  the  patient's  life  is  endangered  by  the 
size  of  the  growth  only.  Should  such  a  tumor  rupture,  or  the 
papillomatous  outgrowths  perforate  the  capsule  and  extend 
into  the  abdominal  cavity,  it  is  no  less  malignant  than  a 
sarcoma  or  carcinoma. 

Accidents. — An  ovarian  tumor  is  liable  to  a  number  of 
accidents.  Its  outer  surface  may  become  inflamed,  its  interior 
may  be  infected  and  suppurate,  and  a  pedunculated  tumor  may 
undergo  torsion  with  sufficient  twisting  of  its  pedicle  to  interfere 
with  the  blood  supply  and  cause  gangrene. 


42  2  DISEASES    OF   THE    OVARIES 

Inflammation  of  the  outer  surface  of  an  ovarian  tumor  is  indi- 
cative of  a  mild  localized  peritonitis.  This  is  of  no  particular 
moment  at  the  time  of  its  occurrence,  but  the  resulting  ad- 
hesions may  seriously  compHcate  an  operation  undertaken  for 
the  removal  of  the  tumor  at  a  later  date.  It  is  characterized 
by  slight  elevation  of  temperature  and  localized  pain  and 
tenderness,  both  of  which  subside  in  the  course  of  a  few  days. 

Suppuration  of  an  ovarian  cyst  is  a  rare  accident,  and  when 
it  occurs  is  likely  to  be  associated  with  typhoid  fever.  It  is 
characterized  by  abdominal  pain,  rapid  increase  in  the  size  of 
the  tumor,  sudden  elevation  of  pulse  and  temperature,  and 
leiicocytosis.  Although  suppuration  is  rare  its  diagnosis  is 
not  difficult  if  a  patient  with  typhoid  fever  or  other  general 
infection  is  known  to  have  an  ovarian  tumor,  but  should  the  tumor 
be  small  and  its  presence  unknown,  the  diagnosis  is  not  so 
readily  established.  A  combination  of  abdominal  pain,  leu- 
cocytosis,  and  septic  symptoms  during  or  after  typhoid  always 
means  an  intercurrent  infection  of  some  sort,  and  if  the  patient 
is  a  woman,  the  absence  of  an  ovarian  tumor  should  be  definitely 
established  before  a  diagnosis  of  appendicitis,  cholecystitis,  or 
intestinal  perforation  is  made.  The  treatment  of  this  accident 
is  a  grave  matter.  With  a  large  cyst  undergoing  suppuration 
and  a  patient  already  reduced  by  serious  illness,  ovariotomy  is  a 
desperate  procedure.  Rupture  of  the  tumor  during  its  removal, 
or  soiling  of  the  abdominal  cavity  by  its  infected  contents, 
almost  certainly  leads  to  death.  Under  such  circumstances  it 
may  be  necessary  to  open  the  abdominal  cavity  under  local 
anaesthesia,  wall  off  an  area  immediately  beneath  the  incision, 
and  allow  adhesions  to  form  for  24  or  48  hours,  after  which  the 
tumor  can  be  tapped  and  drained.  This  is  an  imperfect 
procedure  and  should  not  be  resorted  to  save  in  the  direst  ex- 
tremity, but  in  desperate  cases  it  may  be  life  saving.  When 
the  tumor  is  small  and  the  patient  in  reasonably  good  con- 
dition, rapid  removal  without  tapping  offers  the  most  hope  of 
relief. 


ACCIDENTS    TO    TUMORS    OF    THE    OVARY 


423 


Fig.  213. — Drawn  from  specimen  of  torsion  of  pedicle  of  an  ovarian  cyst. 


424  DISEASES    OF    THE   OVARIES 

Torsion  of  the  pedicle  of  an  ovarian  tumor  takes  its  place 
among  the  abdominal  catastrophies.  The  symptoms  are  in- 
tense pain,  profound  shock,  and  marked  tenderness  to  pressure 
over  the  location  of  the  tumor,  followed  after  a  short  time  by 
evidences  of  severe  peritonitis.  Usually  there  is  vomiting,  and 
when  this  is  present  the  symptoms  of  acute  intestinal  strangula- 
tion are  very  closely  imitated.  The  diagnosis  is  readily  es- 
tablished when  a  patient  who  is  known  to  have  an  ovarian 
tumor  develops  the  foregoing  set  of  symptoms;  and  whenever 
a  woman  presents  the  symptoms  of  intestinal  obstruction  the 
absence  of  an  ovarian  cyst  should  be  definitely  determined, 
although  the  treatment  is  the  same  in  either  event,  viz.,  im- 
mediate operation. 

Upon  opening  the  abdomen  of  such  a  patient  the  tumor  will 
be  found  discolored,  blue  if  venous  return  only  is  interfered  with, 
black  if  the  circulation  is  completely  cut  off.  A  moderate 
degree  of  torsion  of  the  pedicle  which  is  sufficient  to  interfere 
with  the  venous  return  only,  causes  a  much  more  rapid  increase 
in  the  size  of  the  growth  than  does  torsion  so  complete  as  to 
interfere  with  both  the  arterial  supply  and  the  venous  return. 
In  the  latter  event  there  is  likely  to  be  a  very  deceptive  remis- 
sionjn  the  symptoms  between  the  time  when  gangrene  occurs 
and  septic  peritonitis  begins. 

The  removal  of  an  ovarian  tumor  with  torsion  of  its  pedicle 
does  not  differ  from  the  performance  of  ovariotomy  under 
ordinary  circumstances,  excepting  that  the  tumor  should  not 
be  tapped  and  its  pedicle  should  be  ligated  well  below  the 
thrombosed  area. 

Symptoms  and  Diagnosis  of  Ovarian  Tumors. — Aside  from 
the  pain  caused  by  retention  cysts  and  the  pain  associated  with 
malignant  tumors  which  have  involved  the  peritoneum,  the 
early  subjective  evidences  of  ovarian  tumors  may  be  surpris- 
ingly trivial  if  none  of  the  accidents  occur.  The  only  complaint 
which  the  patient  makes  may  be  that  of  a  sensation  of  fullness 
in  the  lower  abdomen,  and  the  diagnosis  depends  entirely  upon 


DIAGNOSIS   OF   TUMORS    OF   THE   OVARY  425 

the  results  of  a  physical  examination.  Upon  inspection  of  the 
abdomen  it  will  be  found  prominent  in  proportion  to  the  size 
the  tumor  has  assumed;  in  the  small  tumors  no  change  is 
appreciable  upon  inspection,  in  those  of  moderate  size  there 
will  be  a  fullness  in  one  or  the  other  hypogastric  region.  Upon 
palpation  of  a  large  ovarian  tumor  there  is  felt  a  distinct, 
semi-elastic,  rounded,  mass,  which  usually  is  regular  in  shape 
but  may  be  lobulated.  When  the  tumor  is  small  it  will  be 
found  to  one  side  of  the  pelvis,  but  later  it  occupies  the  mid- 
line unless  it  has  contracted  adhesions  in  its  original  location. 
Percussion  directly  over  the  tumor  gives  a  fiat  note,  although 
coils  of  intestine  may  overlie  it  when  small  and  remain  be- 
tween the  tumor  and  abdominal  wall  if  they  become  adherent,  in 
which  event  there  will  be  local  areas  of  tympany.  At  either 
side  of  the  growth  percussion  gives  a  resonant  note  unless 
ascites  co-exists.  Fibromata,  sarcomata,  and  carcinomata  are, 
however,  almost  invariably  accompanied  by  ascites,  when  the 
absence  of  resonance  at  the  sides  is  of  no  value.  Auscultation 
is  without  result.  Upon  bi-manual  examination  the  tumor  is 
perceptible  to  the  vaginal  finger  unless  it  happens  to  be  adherent 
high  in  the  abdomen.  The  uterus  can  be  made  out  in  front, 
behind,  or  at  one  side  of  the  tumor,  and  occasionally  a  distinct 
pedicle  can  be  palpated.  If  the  tumor  is  cystic  and  not  too 
tense,  a  sense  of  semi-iiuctuation  can  be  obtained  between  the 
fingers  in  the  vagina  and  the  hand  upon  the  abdomen,  and,  if 
of  moderate  size  and  not  adherent,  it  will  be  freely  movable. 
When,  on  the  contrary,  the  growth  is  very  large,  the  tension 
of  the  abdominal  wall  may  be  sufficient  to  prevent  motion 
being  conveyed  to  it  by  the  vaginal  finger,  and  if  the  tumor  is 
one  of  the  solid  varieties  no  fluctuation  or  sense  of  elasticity 
can  be  obtained.  Parovarian  cysts,  contrary  to  the  rule  with 
true  ovarian  tumors,  are  not  movable. 

The  differential  diagnosis  of  a  small  ovarian  tumor  is  easy,  and 
it  is  almost  impossible  to  mistake  it  for  any  other  tumor  ex- 
cepting a  pedunculated  fibroid  or  a  hydrosalpinx.     Its  painless 


426  DISEASES    OF    THE    OVARIES 

character,  and  in  other  than  adherent  retention  cysts,  its  free 
mobihty,  scarcely  allows  it  to  be  confused  with  any  other  pelvic 
disease.  Occasionally  a  hydrosalpinx  presents  all  the  charac- 
teristics of  a  small  ovarian  cyst  and  it  may  be  impossible  to 
differentiate  one  from  the  other,  but  such  differentiation  is  of 
importance  from  a  prognostic  standpoint  only  as  both  require 
operative  treatment. 

With  the  larger  tumors,  however,  a  number  of  conditions 
may  be  confused,  the  principal  ones  being  pregnancy,  large 
libro-myomata,  ascites,  and  late  tuberculous  peritonitis. 

It  cannot  be  repeated  too  often,  that  the  pregnant  uterus  is 
the  most  common  source  of  abdominal  enlargement  in  women 
throughout  the  child-bearing  age.  While  the  differentiation  of 
a  pregnant  uterus  from  an  ovarian  tumor  usually  is  easy,  con- 
ditions sometimes  arise  which  render  it  extremely  difficult. 
Should  a  tumor  occur  in  a  young  girl,  that  is,  two  or  three  years 
before  puberty,  or  if  it  presents  itself  in  a  woman  several  years 
beyond  the  menopause,  no  thought  of  pregnancy  need  be  enter- 
tained, but  during  the  child-bearing  age  pregnancy  must  always 
be  considered.  On  inspection  of  the  abdomen  both  present  a 
midline  enlargement,  symmetrically  rounded,  and  shading  off 
at  the  sides.  On  palpation  an  elastic  mass  can  be  felt  in  both 
conditions,  regular  in  shape,  and  extending  from  the  pelvis 
upward  into  the  abdomen.  The  pregnant  uterus  is  always 
smooth  and  an  ovarian  cyst  usually  so.  Ordinarily  the  cyst  is 
the  tenser  of  the  two,  but  if  the  hand  remains  flat  upon  the 
abdomen  for  a  sufficient  time  the  pregnant  uterus  can  be  felt 
to  undergo  alternate  contraction  and  relaxation,  in  which  the 
uterus  differs  from  any  abdominal  neoplasm,  and  from  any 
other  abdominal  organ  excepting  an  obstructed  stomach  or 
intestine. 

On  percussion  the  results  are  similar  in  both  cases,  flatness 
over  the  enlargement,  tympany  at  both  sides  and  above  it. 

Should  the  tumor  be  as  large  as  a  seven  months'  pregnant 
uterus,  auscultation  reveals  one  positive  finding  in  pregnancy 


DIAGNOSIS    OF   TUMORS    OF   THE    OVARY  427 

which  is  absent  in  ovarian  cysts,  viz.,  the  uterine  bruit  synchro- 
nous with  the  maternal  pulse  rate.  If  the  foetus  is  living,  the 
foetal  heart  also  should  be  audible  at  and  beyond  this  period, 
and  if  the  examination  is  prolonged,  foetal  motion  should  be  both 
heard  and  felt. 

Upon  inspecting  the  vulva  during  pregnancy  the  char- 
acteristic discoloration  is  visible,  and  after  three  or  four  months 
is  almost  unmistakable.  No  discoloration  is  present  in  ova- 
rian tumors  unless  they  are  adherent  and  impacted.  The 
cervix  in  pregnancy  feels  soft  to  the  touch,  in  ovarian  tumors 
normal. 

On  bi-manual  examination  the  enlargement  of  pregnancy 
is  an  integral  part  of  the  uterus,  while  the  uterus  usually  can 
be  outlined  somewhere  outside  an  ovarian  tumor. 

In  pregnancy  some  of  the  foetal  parts  ordinarily  can  be  out- 
lined on  bi-manual  examination  and  motion  will  be  felt  if  the 
foetus  is  alive,  but  an  occasional  case  of  hydramnios  is  encoun- 
tered in  which  the  tension  of  the  uterine  walls,  together  with 
an  excessive  quantity  of  fluid,  obscures  this  sign. 

The  patient's  history  adds  some  weight  but  is  not  always 
reliable,  as  menstruation  may  continue  or  be  said  to  have  con- 
tinued during  pregnancy,  and  may  cease  when  the  patient  has  a 
huge  ovarian  cyst.  The  breast  signs  of  pregnancy  are  equally 
unreKable,  colostrum  appearing  in  various  pelvic  disorders  as 
well  as  in  pregnancy. 

The  sound  may  be  used  in  instances  of  grave  doubt  when  im- 
mediate diagnosis  is  demanded,  but  only  under  such  circum- 
stances is  it  justifiable  as  pregnancy  is  always  diagnosable  by 
its  ultimate  termination  in  labor. 

The  differentiation  of  large  fibro-myomata  of  the  uterus  from 
tumors  of  the  ovary  is  not  so  important  as  is  the  exclusion  of 
pregnancy,  as  the  treatment  of  both  is  operative,  but  the  prog- 
nosis of  the  two  is  by  no  means  similar.  For  the  sake  of  a 
definite  prognostic  statement  as  well  as  in  the  interest  of  scien- 
tific accuracy  this  differentiation  should  be  made  when  possible, 


428  DISEASES   OF   THE   OVARIES 

and  the  reader  is  referred  to  the  section  devoted  to  fibro- 
myomata  for  the  differential  points. 

Between  ascites  and  ovarian  tumor  the  points  of  similarity 
are  few,  and  one  might  say  that  the  only  resemblance  lay  in  there 
being  an  ill  patient  with  an  enlarged  abdomen.  The  fluid  in 
ovarian  cysts  is  enclosed  in  a  capsule,  in  ascites  it  is  free;  but 
ovarian  fibroids,  carcinomata  and  sarcomata  have  ascites  as- 
sociated with  them  when  the  physical  signs  both  of  ascites  and 
a  tumor  are  present.  Upon  change  of  position  a  movable  area 
of  dullness  is  characteristic  of  ascites,  and  while  ovarian  tumors 
move  on  change  of  position,  they  move  as  one  mass  and  not  as 
free  fluid  with  intestine  floating  upon  its  surface. 

It  should  not  be  assumed  that  the  ascites  arises  from  some 
general  disease  unless  heart,  kidney,  liver,  or  advanced  lung 
lesions  are  present.  Tuberculous  peritonitis  may  simulate  an 
adherent  ovarian  tumor,  but  elevation  of  temperature,  a  per- 
sistently fast  pulse,  and  emaciation  all  point  to  tuberculous 
peritonitis  rather  than  ovarian  tumor. 

Treatment. — The  treatment  of  ovarian  tumors  is  surgical. 
Small  retention  cysts  and  corpus  luteum  cysts  can  often  be 
removed  by  resection  of  the  ovary,  but  complete  excision  is 
demanded  for  all  others. 

Occasionally  a  parovarian  tumor  may  rupture  and  not  refill, 
but  as  a  rule  their  treatment  is  the  same  as  that  of  the  true 
ovarian  cysts. 

OPERATIONS  UPON  THE  OVARIES 

A  retention  cyst  or  a  corpus  luteum  cyst  of  one  ovary  may  be 
treated  by  removal  of  that  ovary  if  the  other  is  normal,  but 
resection  is  the  operation  of  choice  when  both  ovaries  are 
involved. 

Resection.^ — After  the  abdomen  is  opened  the  intestine  is 
packed  away  from  the  lower  pelvis  with  gauze  pads,  both  to 
prevent  soiHng  if  the  cyst  should  rupture  and  to  obviate 
constant  handling  of  the  bowel.     Most  retention  cysts  are  the 


OVARIOTOMY 


429 


aftermath  of  acute  oophoritis  and  are  therefore  adherent  to 
the  broad  ligament,  intestine,  or  floor  of  the  pelvis.  The  ad- 
hesions which  bind  the  ovary  to  these  locaHties  are  separated 
gently,  and  the  ovary  is  drawn  to  the  surface.  A  wedge-shaped 
excision  of  all  the  affected  area  is  then  made  and  the  flaps  united 
with  interrupted  sutures  of  fine  silk  or  catgut,  appHed  just 
tightly  enough   to   control  bleeding.     No   sutures  should  be 


Fig.  214. — Resection  of  ovary. 


A  wedge-shaped  excision  of  all  the  affected  area 
is  made. 


placed  upon  the  broad  Hgament  external  to  the  ovary  for 
fear  that  deprivation  of  its  main  blood  supply  will  cause  further 
degeneration  and  subsequently  necessitate  a  total  removal  of 
the  organ. 

Ovariotomy. — Ovariotomy  was  the  earHest  routine  abdominal 
operation  undertaken  deliberately  with  the  object  of  curing  a 
hitherto  incurable  disease. 


430 


DISEASES    OF   THE   OVARIES 


In  the  absence  of  adhesions  the  operation  is  easy  and  the 
technique  simple,  especially  if  the  tumor  is  of  moderate  size. 

The  abdomen  is  opened  by  a  short  incision  at  or  near  the 
mid-line,  and  the  relations  of  the  tumor  ascertained  with  the 
linger.  If  no  compHcations  are  present  the  incision  is  length- 
ened sufficiently  to  permit  the  tumor  to  be  hfted  out  of  the 
abdominal  cavity,  which  is  at  once  protected  by  gauze  pads 


Fig.  215. — Resection  of  ovary.     Sutures  in  place  but  not  tied. 

tucked  under  the  edges  of  the  incision  in  sufficient  number  to 
retain  the  intestine  and  protect  the  peritoneum  from  drying 
through  contact  with  the  air.  The  pedicle  is  now  clamped  or 
ligated  and  the  tumor  cut  away  at  such  a  distance  from  the 
tumor  that  none  remains  in  the  stump,  but  sufficiently  far 
from  the  clamp  or  Hgature  so  that  retraction  of  the  vessels  is 
impossible.     Temporary  control   of   the  pedicle  by  clamping 


OVARIOTOMY 


431 


is  safer  than  immediate  ligation,  as  after  removal  of  the  tumor 
the  ligature  is  sometimes  found  to  be  loose,  or  to  contain  too 
little  of  the  stump  distal  to  the  tie  to  be  safe. 

If  the  pedicle  is  small,  one  hgature  of  medium-sized  silk 
applied  immediately  proximal  to  the  clamp  and  drawn  tight  as 
the  clamp  is  loosened  is  entirely  satisfactory,  as  it  slips  into  the 
groove  made  by  the  clamp  and  renders  retraction  of  the  vessels 


Fig.  216. — Resection  of  ovary.     Sutures  tied  just  tightly  enough  to  control 
-  bleeding.     No  sutures  at  broad  ligament. 


impossible.  For  thicker  pedicles  many  methods  of  ligation 
have  been  advised,  but  any  method  is  safe  which  controls  the 
vessels  after  the  stump  is  returned  to  the  abdomen. 

A  satisfactory  plan  is  to  perforate  the  pedicle  immediately 
behind  the  clamp  and  tie  it  in  halves,  one  tie  then  being  thrown 
around  the  entire  stump,  always  remembering  to  loosen  the 
clamp  as  the  first  turn  of  the  knot  is  drawn  down. 


432 


DISEASES   OF   THE   OVARIES 


If  greater  security  is  desired  the  latter  part  of  this  ligature 
may  be  made  as  a  suture  which  takes  a  thin  bite  of  peritoneum 


Fig.  217. — Ovariotomy.     Clamping  and  tying  pedicle  in  halves. 


Fig.  2x8. — Ovariotomy.     "The  latter  part  of  this    ligature    may    be  made 

as  a  suture." 


once  or  twice  as  it  encircles  the  pedicle,  and  absolute  safety 
is  attained  by  picking  up  and  tying  each  vessel  after  the  main 


OVARIOTOMY 


433 


Fig.  219. — Ovariotomy.     Adhesions  may  be  prevented  by  "burying  the  stump 

with  a  purse-string  suture." 


Fig.  220. — Ovariotomy.     The  stump  buried. 


28 


434  DISEASES   OF   THE   OVARIES 

ligature  has  been  applied.  The  raw  end  of  the  stump  sometimes 
contracts  adhesions.  This  can  be  prevented  by  burying  the 
stump  with  a  purse-string  suture  placed  on  the  pedicle  proximal 
to  the  main  ligature. 

The  peritoneal  toilet,  so  frequently  mentioned  in  the  early 
descriptions  of  ovariotomy,  is  unnecessary  unless  a  cyst  has 
ruptured  during  the  operation.  In  this  event  the  fluid  is  sponged 
out  at  once  and  the  soiled  area  carefully  gone  over  with  wet 
sponges.  The  contents  of  ovarian  cysts  are  sterile,  but  small 
adenomatous  or  papillomatous  masses  may  graft  themselves 
upon  the  peritoneum  and  multiply  as  independent  tumors,  while 
it  is  almost  impossible  to  remove  the  sebaceous  material  of  a 
dermoid  from  the  peritoneum  and  saprophytic  infection  and 
fatal  peritonitis  may  be  the  outcome. 

Technique  in  the  Presence  of  Adhesions.^ — Adhesions  of  the 
omentum  to  the  growth  are  gently  separated  if  they  are  recent, 
or  tied  and  .cut  between  ligatures  if  old  and  dense.  The  in- 
testine is  packed  away  from  the  location  of  the  tumor  so  far  as 
the  adhesions  will  permit,  and  the  latter  are  separated  by  the 
sense  of  touch  alone  so  long  as  the  dissection  is  easy  and  in 
safe  territory.  Adhesions  to  movable  coils  of  intestine  are  better 
separated  under  the  guidance  of  the  eye,  and  if  they  are  very 
dense  the  outer  layer  of  the  tumor  wall  should  be  left  attached 
to  the  viscera  rather  than  to  denude  the  latter  of  their  peritoneal 
covermg.  Should  the. cyst  rupture  during  these  manuevers  its 
contents  are  carefully  sponged  away  and  the  now  collapsed  cyst 
wall  is  drawn  up  out  of  the  incision,  where  the  separation  of 
adhesions  is  continued.  The  abdominal  cavity  above  and  about 
the  site  of  operation  should  be  most  carefully  walled  off  by 
gauze  packs,  so  that  general  peritoneal  soiling  may  not  take 
place  in  the  event  of  injury  to  the  tumor,  the  bladder,  or  the 
intestine.  Should  such  injury  occur  to  a  viscus  it  is  repaired 
at  once  if  the  damage  impHcates  the  muscular  coat.  At  the 
close  of  an  operation  in  which  the  separation  of  dense  ad- 
hesions has  been  a  feature,  the  intestine  to  which  the  tumor  was 


OVARIOTOMY 


435 


adherent  should  be  carefully  inspected,  and  areas  deprived  of 
peritoneum  be  repaired  by  one  or  two  sutures  taken  in  Lem- 
bert  fashion.  Minute  unprotected  intestinal  injuries  unques- 
tionably are  a  common  cause  of  death  following  the  removal  of 
densely  adherent  tumors.     Once  the  tumor  has  been  liberated, 


Fig.  2  21. — Ovariotomy. 


Very  large   ovarian   cysts  must  first  be  reduced  in 
size  by  tapping. 


the  operation  proceeds  as  previously  described  for  non-adherent 
growths. 

While  the  immense  tumors  of  olden  days  are  rare  at  the 
present  time,  an  occasional  cyst  is  encountered  of  such  size 
that  to  remove  it  intact  would  require  so  long  an  incision  as  to 
seriously  damage  the  integrity  of  the  abdominal  wall.  In 
addition  to  this  the  frequent  presence  of  adhesions  renders  the 
technique   considerably   more   difficult   unless   the   growth  is 


436 


DISEASES    OF   THE   OVARIES 


reduced  in  size,  so  that  cysts  exceeding  the  size  of  a  seven 
months'  pregnant  uterus  are  removed  in  the  following  manner. 
Only  a  short  incision  is  made,  and  after  the  anterior  surface 
of  the  tumor  is  exposed  the  abdominal  wall  is  held  firmly  against 
it  by  the  hands  of  an  assistant  making  pressure  on  the  outside. 


Fig.   2  2  2. — Parovarian    cystectomy.     Incision    through    clear    space   in    broad 
ligament.     Serosa  separated  from  tumor  wall  by  blunt  dissection. 


An  ovarian  trocar  is  then  thrust  into  the  tumor,  and  as  the 
fluid  escapes  and  the  tumor  becomes  flaccid  it  is  gradually 
drawn  through  the  incision.  In  multilocular  cysts  it  is  neces- 
sary to  perforate  the  walls  of  the  daughter  cysts  and  evacuate 
their  contents  before  the  tumor  can  be  withdrawn  completely. 
Adhesions  to  the  viscera  are  stripped  off  by  sponge  pressure 


PAROVARIAN  CYSTECTOMY  437 

as  they  appear  in  the  incision.  At  all  stages  of  the  operation 
care  should  be  exercised  that  the  peritoneal  cavity  is  not  soiled. 

Pedicles  of  these  large  tumors  are  treated  precisely  like  those 
of  the  smaller  ones.  Occasionally  it  will  be  found  that  one  of 
these  growths  has  developed  a  band  of  dense  adhesions  to  the 
bowel,  the  omentum,  or  the  stomach,  in  which  the  vessels  have 
attained  such  extraordinary  size  that  it  may  be  regarded  as  a 
second  pedicle.  This  should  be  ligated  as  carefully  as  the 
true  pedicle.  Occasionally  also,  some  portion  of  the  intestine 
is  so  densely  adherent,  or  so  surrounded  by  the  growth,  that  the 
removal  of  the  latter  is  impossible  without  the  infliction  of 
great  damage  upon  the  intestine,  under  which  circumstances 
resection  may  be  necessary.  The  operator  who  essays  to  re- 
move a  large  adherent  tumor  must  be  prepared  to  cope  with 
any  intestinal  operation  which  the  exigencies  of  the  case  may 
demand. 

Parovarian  Cystectomy. — The  removal  of  a  parovarian  cyst 
demands  a  technique  of  its  own  as  the  tumor  has  no  pedicle, 
is  sessile,  and  its  blood  supply  comes  through  a  broad  base  in 
close  proximity  to  the  ureter. 

The  tumor  first  is  thoroughly  exposed  and  an  area  free 
from  vessels  sought  on  its  broad  ligament  surface.  Through 
this  clear  space  an  incision  is  made  parallel  to  the  tube,  the 
incision  penetrating  the  serosa  only.  Through  this  opening  a 
finger  is  inserted  and  the  tumor  wall,  anteriorly  and  posteriorly 
separated  from  its  broad  ligament  covering  by  blunt  dissection. 
No  attempt  should  be  made  to  approach  the  base  of  the  tumor 
until  the  latter  has  been  sufficiently  freed  to  permit  dissection 
under  guidance  of  the  sight.  Bleeding  points  are  caught 
with  forceps  as  they  are  developed,  but  clamping  of  the  tissue 
in  large  masses  is  dangerous  unless  the  ureter  is  in  plain  view. 
The  entire  growth  having  been  freed  excepting  at  its  base, 
the  tumor  is  rolled  from  its  bed,  and  as  the  main  vessels  are 
exposed  they  are  caught  and  cut  individually. 

The  tumor  having  been  removed,  the  vessels  are  ligated  with 


438  DISEASES   OF   THE   OVARIES 

plain  catgut  and  the  margins  of  the  peritoneal  opening  are 
approximated  by  a  running  suture. 

In  some  cases  it  will  be  found  judicious  to  ligate  the  ovarian 
vessels  both  in  the  infundibulo-pelvic  ligament  and  at  the  uter- 
ine horn,  but  if  this  is  done  the  ovary  should  be  removed  at  the 
same  time  in  order  to  prevent  its  subsequent  degeneration. 

At  other  times  the  blood  supply  is  so  free  that  even  more 
certain  preliminary  haemostasis  is  demanded.  This  can  be 
secured  through  removal  of  the  uterus  by  the  technique  recom- 
mended for  fibroids  which  expand  one  broad  ligament.  The 
ovarian  and  uterine  vessels,  on  the  side  opposite  the  tumor,  are 
clamped  and  cut,  the  body  of  the  uterus  severed  from  the  cervix, 
and  the  uterus  drawn  to  the  diseased  side  until  the  uterine 
artery  on  that  side  is  secured.  After  this  is  caught  and  cut, 
the  uterus  and  tumor  are  rolled  out  still  farther  toward  the 
diseased  side,  in  this  way  exposing  the  blood  supply  to  the  under- 
surface  of  the  tumor  each  vessel  to  which  is  secured  as  it  is 
demonstrated,  while  the  ureter  and  parametrium  are  brushed 
away  without  injury. 

REFERENCES 

MEYER. — Beitrage  zur  pathologischen  Anatomic  des  Ovariums,  Oophoritis. 

Zeitsch.  f.  Geb.  und  Gyn.y  1913,  Ixxv,  761. 
PALMER. — Prolapse  of  the  Ovary;  Its  Rational  Management.     Am.  J.  M. 

Set.,  1914,  cxlvii,  561. 
RIES. — Zur  Aetiologie  periodischer    und    altermerender   Ovarialschwellungen. 

Zeitsch.  f.  Geb.  und  Gyn.,  1913,  Ixxiv,  312. 
STRATZ. — Lageveranderungen  der  Ovarien.     Zeitsch.  f.  Geb.  und  Gyn.,  19 10, 

Ixv,  283. 
SCHARLIEB,  MARY.— On  the  Proportion  of  Malignant  to  Innocent  Ovarian 

Growths,  Founded  on  a  Series  of  150  Cases.    Proc.  Roy.  Soc.  of  Med.,  1910; 

Obst.  &*  Gyn.  Sec,  iii,  85. 
BARRIS. — Primary  Carcinoma  of  the  Ovary.    Proc.  Roy.  Soc.  of  M.,   191 2; 

Obst.  b"  Gyn.  Sect.,  v,  115. 
GOODALL.— The  Origin  of  Epithelial  New  Growths    of  the  Ovary.     Surg., 

Gyn.  cr  Obst.,  191 2,  xiv,   584. 
MacCARTY  AND  SISTRUNK.— Benign  and  Malignant  Ovarian  Cysts.     Surg., 

Gyn.  is"  Obst.,  1913,  xvii,  41. 
WHITE. — Ovarian  Teratomata.     Am.  J.  Obst.,  1913,  Ixviii,  236. 


REFERENCES  439 

WOLFF. — Das  Alveolarsarkom  des  Ovariums.     Arch.  f.  Gyn.,  1910,  xcii,  721. 
YAMASAKE. — Beitrag  zur  Aetiologie  der  Ovarialdermoide  und  zer  Kenntnis 

der  darin  Vorkommenden  Haare.     Monats.f.  Geb.  und  Gyn.,  1911,  xxxiii,  63. 
CULLEN. — Combined  Adenocarcinoma  and  Mixed  Celled  Sarcoma  of  the  Ovary. 

Johns  Hopkins  Hosp.  Bull.,  191 1,  xxii,  :i)6T. 
KUDOH. — Histogenesis  of  Dermoid  Cysts  of  the  Ovary.     Tr.  Internal.  Cong. 

M.  Lo?id.,  1913;  Abst.  Internal.  Abst.  Surg.,  March,  1914,  282. 
WOLFF. — Anatomischer  Beitrag  zur  Kenntnis  der  malignen  Ovarialdermoide. 

Monats.  f.  Geb.  und  Gyn.,  1911,  xxxiv,  178. 
GOLDSCHMIDT. — Spindelzellensarkom  in  der  Wand  eimer  papillaren  Par- 

ovarialcyste.     Monats.  f.  Geb.  und  Gyn.,  191 1,  xxxiv,  687. 
HAHN. — Ein  Beitrag  zur  Kenntnis  des  Oberflachenpapilloms  des  Ovariums. 

Zeitsch.  f.  Geb.  und  Gyn.,  1914,  Ixxvi,  28. 
BAUER. — Ueber  die  sogenannte   Struma  Ovarii.     Zeitsch.  f.  Geb.  und  Gyn., 

1914,  Ixxv,  617. 

WIENER. — The  Clinical  Malignancy  of  Pseudomucinous  Cystadenoma  of  the 

Ovary.     Am.  J.  Obst.,  1914,  Ixix,  1015. 
WILSON. — On  Gelatinous  Glandular  Cysts  of  the  Ovary  and  the  So-called 

Pseudomyxoma  of  the  Peritoneum.     /.  Obst.  &'  Gyn.,  Brit.  Emp.,  1912,  xxii, 

191. 
EKLER. — ijber  Ovarial  und  Parovarialtumoren.     Monats.  f.  Geb.  und  Gyn., 

1913,  xxxviii,  523;  Abst.  Internal.  Abst.  Surg.,  June,  1914. 
MAIER. — Post-typhoid    Suppuration    of   an   Ovarian    Cyst   Infected   by    the 

Bacillus  Typhosus  of  Eberth.     Am.  J.  Obst.,  1914,  Ixix,  821. 
WIENER. — A  Study  of  the  Complications  of  Ovarian  Tumors.     Am.  J.  Obst., 

1915,  Ixxii,  209. 

FULLERTON. — Typho-tuberculous    Tubo-ovarian    Abscess.     Surg.,    Gyn.    & 

Obst.,  1913,  xvi,  180. 
BARRETT. — Ovarian   Tumors    Complicating    Pregnancy,    Delivery,    and    the 

Puerperium.     Surg.,  Gyn.  b'  Obst.,  1913,  xvi,  28. 
JELLINGHAUS  AND  LOSEE.— The   Serum  Diagnosis  of  Pregnancy.     Am. 

J.  Obst.,  1 9 14,  Ixix,  593. 
GOLDSPOHN. — Resection  of  Ovaries.     Trans.  Am.  Assn.  Obst.  &"  Gyn.,  1914, 

xxxii,  71. 
OHMAN. — tJber   Ovarialbluntungen  und   Ovarialhamatom.     Monats.  f.  Geb. 

und  Gyn.,  1913,  xxxviii,  283. 
TUFFIER. — Transplantiation  of  Ovaries.     Surg,,  Gyn.  dr  Obst.,  19 15,  xx,  30. 
BARKLEY. — Some  Facts  not  Generally  Known  Regarding  Ephriam  McDowell. 

Surg.,  Gyn.  or  Obst.,  191 2,  xv,  496. 
POLAK. — A    Further    Study  of    the    End  Results    of    the    Conserved    Ovary. 

/.  A.  M.  A.,  1912,  lix,  2138. 
POZZI. — The  Evolution  of  Ovariotomy  in  France.     Surg.,  Gyn.  6"  Obst.,  1909, 

ix,  417. 
BLAND. — The  Abdominal  Incision  in  the  Treatment  of  Ovarian  Cysts.     Surg., 

Gyn.  &  Obst.,  1913,  x\di,  576. 


CHAPTER  XIV 
PELVIC  PERITONITIS,  PELVIC  CELLULITIS 

Peritonitis. — Acute  peritonitis  may  be  classified  as  local, 
diffuse,  and  general. 

The  term  local  peritonitis  implies  that  the  inflammatory 
process  is  confined  to  one  of  the  anatomical  subdivisions  or 
regions  of  the  abdominal  cavity. 

By  diffuse  peritonitis  is  meant  a  spreading  inflammation 
which  overruns  the  boundaries  of  the  anatomical  region  first 
involved,  perhaps  extending  over  a  considerable  portion  of  the 
peritoneum  lining  the  abdominal  cavity.  Diffuse  peritonitis 
often  is  improperly  called  general  peritonitis,  the  latter  term, 
when  correctly  used,  meaning  a  universal  inflammation  of  the 
entire  peritoneal  surface. 

Peritonitis  is  sometimes  defined  according  to  its  microbic 
origin,  as  gonococcus  peritonitis,  staphylococcus  peritonitis, 
streptococcus  peritonitis,  colon  bacillus  peritonitis,  or  pneumo- 
coccus  peritonitis.  Occasionally  one  sees  the  term  peritonitis 
modified  by  the  name  of  the  organ  in  which  the  infection  origi- 
nated, as  appendicular  peritonitis  or  gall-bladder  peritonitis. 

Peritonitis  which  involves  the  pelvic  peritoneum  only  differs 
in  some  respects  from  that  affecting  other  portions  of  the  ab- 
dominal cavity,  but  on  the  whole  the  inflammatory  process  is 
the  same  wherever  it  occurs. 

Pelvic  peritonitis  is  so  frequently  due  to  gonococcus  infection 
that  it  is  more  likely  to  remain  localized  than  is  peritonitis  in 
other  regions  as,  for  example,  the  epigastric.  On  the  other 
hand  infectious  material  gravitates  to  the  lowest  portion  of  the 
abdominal  cavity  and  along  the  mesenteric  planes,  and  the 
pelvis  therefore  may  be  involved  in  a  peritonitis  which  origi- 

440 


ETIOLOGY   OF  PERITONITIS  44 1 

nated  elsewhere,  as  from  a  perforated  stomach,  gall-bladder,  or 
appendix. 

The  pelvic  peritoneum  absorbs  less  rapidly  than  the  perito- 
neum which  lines  the  upper  portion  of  the  abdominal  cavity, 
especially  the  lower  surface  of  the  diaphragm,  and  a  larger  area 
of  pelvic  peritoneum  may  be  infected  with  less  serious  conse- 
quences than  a  smaller  area  elsewhere.  It  is  stated  that  peri- 
tonitis as  an  inflammatory  process  is  of  no  moment  the  in- 
fection being  the  only  matter  worth  considering,  but  this  is 
not  strictly  true  since  inflammation  of  the  peritoneum  is  very 
painful,  absorption  of  toxic  products  from  the  peritoneal  cavity 
is  rapid,  and  secondary  intestinal  paresis  with  resulting  stasis 
adds  to  the  pre-existing  microbic  toxaemia. 

Etiology. — Inflammation  of  the  peritoneum  is  caused  by 
trauma,  by  chemical  irritation,  and  by  microbic  infection. 

Peritonitis  from  trauma  is  purely  protective  in  character  and 
gives  rise  to  no  marked  symptoms,  but  it  may  result  in  adhesions. 

Peritonitis  from  chemical  irritation  is  local  in  its  character, 
and  while  it  may  be  severe  it  is  not  dangerous  unless  infection 
is  added.  Infection  is  more  likely  to  take  place  if  either  trau- 
matic or  chemical  irritation  has  lowered  the  resisting  power  of 
the  peritoneum;  otherwise  neither  traumatic  nor  chemical 
peritonitis  are  of  any  importance  excepting  for  the  adhesions 
which  they  produce. 

Gonococcus  peritonitis  excepted,  pelvic  peritonitis  has  a 
microbic  origin,  the  staphylococcus,  streptococcus,  and  colon 
bacillus  being  the  organisms  most  frequently  found.  It  is 
doubtful  whether  peritonitis  arising  from  gonorrheal  infection 
really  is  microbic,  and  it  is  considered  more  likely  that  the  irri- 
tating qualities  of  the  extravasated  gonorrheal  pus  are  re- 
sponsible for  the  inflammatory  process,  rather  than  that  the 
gonococci  grow  arid  multiply  on  the  peritoneum. 

Clinically,  pelvic  peritonitis  is  the  direct  result  of  gonorrheal 
salpingitis,  of  infection  of  the  cervix  and  uterus,  of  perforation 
of  the  uterus,  of  rupture  of  ovarian  abscesses  or  infection  of 


442  PELVIC   PERITONITIS,    PELVIC    CELLULITIS 

haematomata,  and  it  may  arise  from  perforated  viscera  anywhere 
in  the  abdominal  cavity.  The  method  of  infection  from 
salpingitis  and  rupture  of  ovarian  abscess  is  clear.  In  uterine 
and  cervical  infections  it  may  arise  through  direct  continuity 
of  tissue,  no  matter  how  the  original  infection  was  produced. 
Uterine  perforation  only  results  in  peritonitis  when  the  per- 
forating instrument  is  dirty  or  inflicts  damage  on  the  intestine 
or  bladder. 

A  perforated  appendix  may  be  situated  in  the  pelvis,  or  the 
products  of  inflammation  may  gravitate  over  the  brim  into  the 
pelvic  cavity. 

A  perforated  infected  gall-bladder  may  discharge  sufficient 
infectious  material  to  reach  the  pelvic  peritoneum,  and  gastric 
contents  are  quite  constantly  found  in  the  left  side  of  the  pelvic 
cavity  after  perforation  of  ulcers  of  the  stomach  and  duodenum. 
It  may  be  said  with  truth  that  the  pelvic  cavity  is  the  patho- 
logical cess-pool  of  the  abdomen. 

Gross  Pathology. — The  pathological  conditions  found  as  the 
result  of  pelvic  peritonitis  are  dependent  on  the  kind  of  micro- 
organisms present,  their  number,  their  virulence,  and  the  re- 
sistance which  Nature  has  succeeded  in  providing. 

In  the  most  virulent  cases  the  peritoneum  has  a  scalded  shiny 
appearance,  and  there  is  little  or  no  exudate  of  any  kind.  In 
cases  due  to  trauma  or  chemical  irritation  as  well  as  those 
due  to  very  mild  infection,  the  peritoneum  is  reddened,  and  in  the 
pelvic  cavity  there  is  a  moderate  quantity  of  exudate  which 
at  first  is  serous  in  character,  but  which  soon  solidifies  and  binds 
together  the  organs  whose  peritoneal  coats  have  been  involved. 
This  serum  is  sometimes  clear,  sometimes  cloudy,  but  if  the 
infecting  agent  is  at  all  virulent  it  rapidly  becomes  purulent. 

Occasionally  one  sees  large  masses  of  white  fibrinous  exudate 
occurring  in  patches  or  plaques  which  are  friable  and  easily 
broken  away  from  the  underlying  viscera,  leaving  a  raw  bleed- 
ing surface  beneath  their  site  of  attachment.  The  intestine 
whose  peritoneum  is  involved  is  alv/ays  paretic,  possibly  from 


SYMPTOMS   AND   DIAGNOSIS   OF   PERITONITIS  443 

infiltration  of  its  muscular  structure,  possibly  from  the  influence 
of  absorbed  toxic  products  on  its  nervous  mechanism. 

Symptoms  and  Diagnosis.— The  symptoms  of  pelvic  peritonitis 
vary  widely  according  to  the  virulence  of  the  infection  and  the 
manner  in  which  the  infecting  agent  has  gained  access  to  the 
peritoneal  cavity. 

In  the  most  virulent  type,  due  to  intestinal  perforation  for 
example,  the  shock  of  perforation  may  be  succeeded  by  a  viru- 
lent, rapidly  fatal,  general  peritonitis,  with  no  symptoms  save 
pain  and  vomiting.  One  may  assume  that  in  such  a  case  the 
virulence  and  number  of  the  infecting  organisms  is  so  great  that 
death  occurs  before  Nature's  protective  mechanism  can  provide 
any  resistance,  and  that  on  this  account  there  is  an  absence  of 
the  usual  symptoms. 

Ordinarily  the  first  symptom  of  peritonitis  is  pain,  and  this 
is  of  two  types,  the  characteristic  lancinating  pain  which  ap- 
parently is  independent  of  any  intestinal  movement,  and  the 
colicky  irregular  pain  produced  by  intestinal  peristalsis.  The 
pain  of  peritonitis  is  severe,  and  its  greatest  intensity  is  in  and 
about  the  region  involved.  While  visceral  colic,  like  appendicu- 
lar coHc,  may  be  referred  to  the  epigastrium,  peritonitis  about 
an  inflamed  appendix  leads  to  characteristic  pain  in  the  right 
iliac  fossa. 

Shortly  aft^r  the  onset  of  pain  vomiting  is  likely  to  take  place, 
and  it  may  remain  a  striking  feature  throughout  the  course  of 
the  disease,  the  vomited  material  consisting  of  stomach  contents 
and  bile.  Usually  marked  constipation  is  present,  but  occasion- 
ally the  bowels  are  loose  and  the  passages  foetid.  The  pulse  is 
always  more  rapid  than  normal  and  in  any  but  the  most  severe 
cases  the  temperature  is  elevated,  but  the  degree  of  fever  is 
no  indication  of  the  severity  of  the  infection,  both  the  rate 
and  character  of  the  pulse  being  a  far  better  guide  than  the 
temperature. 

Inspection  of  the  abdomen  shows,  first  and  most  prominently, 
a  restriction  in  the  respiratory  excursions  of  the  abdominal  wall, 


444  PELVIC   PERITONITIS,    PELVIC    CELLULITIS 

an  extremely  severe  case  of  diffuse  or  general  peritonitis  reveal- 
ing a  perfectly  immobile  abdomen. 

Auscultation  of  the  abdomen  in  the  latter  form  may  show  a 
total  absence  of  peristalsis,  the  respiratory  and  cardiac  sounds 
being  heard  with  startling  distinctness.  In  peritonitis  limited 
to  the  pelvis  the  upper  abdomen  moves  with  respiration  and 
the  usual  peristaltic  gurgling  is  heard  with  the  stethoscope,  the 
louder  sounds  often  coinciding  with  attacks  of  colicky  pain. 
Very  light  pressure  upon  the  abdominal  wall  elicits  superficial 
hyperaesthesia  over  the  inflamed  area  as  it  is  supplied  from  the 
same  spinal  cord  segments  as  the  skin  overlying  it.  Deeper 
pressure  brings  out  the  protective  rigidity  of  the  abdominal 
muscles  which  is  almost  always  present  in  peritonitis,  although 
it  is  more  distinct  when  this  affection  is  above  the  pelvic  brim. 
Some  tympany  is  present  in  every  case  unless  it  be  of  the 
virulent  type  which  reaches  a  fatal  termination  within  a  few 
hours.  Examination  of  the  blood  shows  a  polymorphonuclear 
leucocytosis,  the  degree  of  leucocytosis  corresponding  somewhat 
to  the  severity  of  the  infection  but  being  far  from  an  infallible 
guide. 

On  making  a  vaginal  examination,  if  the  peritonitis  is  pelvic, 
the  atrium  of  infection  may  be  discovered  in  a  gonorrheal 
discharge,  or  evidence  of  a  recent  abortion  or  delivery.  If 
the  inflammation  is  limited  to  one  side  motion  conveyed  to 
the  uterus  causes  pain  on  that  side,  and  there  is  marked  tender- 
ness to  pressure.  As  the  disease  progresses  and  the  fibrin 
content  of  the  peritoneal  serum  solidifies,  a  noticeable  swell- 
ing makes  its  appearance  above  the  vaginal  vault,  and  the 
general  symptoms  may  abate  at  this  time  owing  to  localization 
of  the  infection  and  diminution  in  the  rapidity  of  absorption 
of  toxic  products  from  the  infected  area.  Should  suppuration 
not  supervene  the  temperature  and  pulse  fall,  the  pain  lessens, 
the  appetite  returns,  the  bowels  respond  more  readily  to 
enemas,  and  the  facial  expression  notably  improves.  Should 
the  pulse  and  temperature  continue  elevated  over  many  days 


SYMPTOMS   AND  DIAGNOSIS   OF  PERITONITIS  445 

with  more  or  less  constant  pain  and  tenderness,  it  is  fair  to 
assume  that  suppuration  is  taking  place  somewhere  in  the  mass 
of  exudate  which  fills  the  pelvic  cavity,  providing  of  course  the 
original  infection  is  not  responsible  for  continuation  of  the 
symptoms.  Gonorrheal  pyosalpinx  may  cause  protraction  of 
the  symptoms  for  many  weeks  without  suppuration  outside  the 
tube.  On  the  other  hand,  both  pulse  and  temperature  may 
approximate  normal  while  a  large  pelvic  abscess  is  forming  if 
the  latter  is  well  walled  in,  but  the  patient  continues  to  suffer 
pain,  and  the  expression  of  the  face  indicates  serious  illness. 

When  suppuration  occurs  in  the  pelvic  cavity  the  abscess 
usually  points  in  the  direction  of  the  vaginal  vault  and  causes 
an  increasing  swelling  at  that  point  whose  growth  can  be  ob- 
served from  day  to  day,  and  sooner  or  later  an  area  of  softening 
can  be  detected  by  the  examining  finger.  Rarely  the  onset  of 
suppuration  is  signaHzed  by  a  chill,  but  no  dependence  whatever 
can  be  placed  upon  the  absence  of  this  symptom. 

In  some  cases  the  abscess  points  toward  the  rectum,  when 
there  will  be  more  or  less  rectal  tenesmus  and  discharge  of 
mucus.  On  examination  through  the  anus  the  sphincter  will 
be  found  relaxed  with  a  bulging  swelling  above  it  which  is 
palpable  to  the  examining  finger. 

These  symptoms  are  so  pathognomonic  of  an  abscess  point- 
ing toward  the  bowel,  that  rectal  tenesmus  with  the  passage  of 
mucus  during  an  attack  of  pelvic  peritonitis,  should  always  lead 
to  examination  by  this  route. 

The  diagnosis  of  pelvic  peritonitis  is  usually  made  by  a 
consideration  of  the  symptoms  and  physical  findings  above  pre- 
sented, but  a  mistake  as  between  pelvic  peritonitis,  intestinal 
obstruction,  and  ruptured  extra-uterine  pregnancy  is  fairly 
frequent. 

In  peritonitis  limited  to  the  pelvis,  the  vomiting  is  never 
fecal  in  odor  and  constipation  is  not  absolute.  There  is  sharp 
lancinating  pain  as  well  as  that  which  is  colicky,  peristalsis  is 
never  violent  as  in  obstruction,  and  visible  intestinal  coils  are 


446  PELVIC   PERITONITIS,    PELVIC   CELLULITIS 

not  observed  in  peritonitis,  the  distension  being  uniform  and 
smooth.  The  pulse  may  be  bad  in  obstruction,  but  the  tem- 
perature is  not  disturbed  and  neither  flatus  nor  fecal  matter  are 
expelled.  In  extra-uterine  pregnancy  after  the  period  of  rup- 
ture, the  symptoms  may  closely  mimic  those  of  low-grade 
peritonitis,  indeed  traumatic  peritonitis  is  present  about  the 
effused  blood,  but  the  extreme  anaemia  is  not  a  factor  in  peri- 
tonitis as  it  is  in  ruptured  tubal  pregnancy.  An  accurate 
history  of  preceding  cystitis  and  vaginitis,  attempted  abortion, 
or  instrumental  interference  with  the  uterus,  leads  to  a  strong 
presumption  of  peritonitis  as  soon  as  abdominal  symptoms 
occur,  but  it  should  not  be  forgotten  that  criminal  abortion  has 
more  than  once  been  attempted  in  cases  in  which  the  pregnancy 
really  was  tubal. 

To  diagnose  the  type  of  peritonitis  correctly  and  thus  be 
able  to  make  an  accurate  prognosis  and  institute  proper  treat- 
ment is  more  difficult  than  to  establish  the  fact  that  peri- 
tonitis exists. 

Prognosis. — A  history  of  gonorrhea  or  the  presence  of  gono- 
cocci  in  the  urethral  or  cervical  discharge,  leads  to  the  presump- 
tion that  a  leaking  tube  is  the  cause  of  the  peritoneal  inflamma- 
tion, but  the  possibiUty  that  a  patient  has  acquired  gonorrhea 
after  becoming  pregnant,  or  that  appendicitis  has  supervened 
in  a  patient  who  already  has  gonorrhea,  must  be  taken  into 
account.  Exclusion  of  other  possible  causes  of  peritonitis  and 
positive  findings  regarding  gonorrhea,  gives  an  entirely  hopeful 
view  to  the  prognosis  so  far  as  life  is  concerned.  The  course  of 
gonorrheal  peritonitis  may  be  long  drawn  out,  but  recovery  from 
the  acute  infection  is  almost  certain  regardless  of  its  apparent 
severity.  Even  the  most  virulent  types  of  peritonitis  will  re- 
cover if  the  infection  remains  localized  in  the  pelvis,  the  grave 
prognosis  of  peritonitis  after  labor  being  due  to  its  rapid 
spread  throughout  the  entire  abdominal  cavity.  Peritonitis 
following  an  infected  abortion  often  extends  to  the;*general 
peritoneum  if  the  infection  is  streptococcic.     Staphylococcus 


TREATMENT   OF   PERITONITIS  447 

infection  is  usually  less  serious,  and  that  from  the  staphylococcus 
albus  is  quite  certain  to  remain  localized. 

A  knowledge  of  the  source  from  which  the  infection  arose  and 
the  character  of  the  invading  micro-organisms  is  thus  helpful 
in  formulating  a  correct  prognosis.  Diffuse  peritonitis  which  is 
spreading  from  the  pelvis  upward  may  often,  be  checked  by 
proper  treatment,  but  true  general  peritonitis  is  almost  uni- 
formly fatal.  The  outlook  is  very  bad  indeed  if  with  abdominal 
evidences  of  severe  peritonitis  the  pulse  is  thready  and  running, 
the  extremities  cool  and  cyanosed,  vomiting  is  without  effort, 
and  the  vomited  material  is  thin  and  black. 

The  facial  expression  also  is  indicative  of  the  condition  of  the 
patient.  The  face  may  express  apprehension,  severe  pain,  etc., 
in  a  hopeful  case,  but  in  fatal  cases  of  general  peritonitis  the  whole 
aspect  is  that  of  a  patient  already  moribund. 

Treatment. — The  treatment  of  pelvic  peritonitis  by  the  surgi- 
cal removal  of  its  cause  would  seem  to  be  the  logical  method  of 
procedure,  but  the  hazards  associated  with  such  radical  opera- 
tions when  infected  tubes  and  ovaries  are  responsible  have  been 
sufficiently  dwelt  upon.  If  the  cause  is  a  perforated  or  inflamed 
viscus  or  an  inflamed  appendix  the  risk  of  operation  is  less  than 
the  risk  of  a  waiting  poHcy,  providing  operation  is  not  delayed 
until  the  stage  of  vaso-motor  paresis,  cyanosis  of  the  extrem- 
ities, etc. 

In  a  general  way,  peritonitis  of  gonorrheal  origin  demands  pal- 
liative and  symptomatic  treatment  only.  Peritonitis  arising 
from  ovarian  infection  or  from  the  infection  of  a  small  uterus 
demands  early  drainage  through  the  posterior  vaginal  fornix. 
Peritonitis  from  a  perforated  viscus,  whether  in  the  pelvis  or 
above  it,  demands  early  abdominal  section  with  removal  or  • 
repair  of  the  perforated  organ. 

The  medical  treatment  of  pelvic  peritonitis  is  formulated 
under  the  treatment  of  acute  salpingitis,  as  the  latter  disease  is 
but  rarely  distinguishable  from  the  peritonitis  which  it  causes. 
Briefly  restated  this  consists  in  the  avoidance  of  cathartics,  abso- 


448  PELVIC   PERITONITIS,    PELVIC    CELLULITIS 

lute  rest  in  bed,  elevation  of  the  head  of  the  bed,  the  use  of  the 
ice-bag  over  the  pelvis  (or  heat  if  cold  is  disagreeable),  and  sed- 
atives in  sufficient  doses  to  allay  pain,  together  with  a  restricted 
diet  and  simple  enemas.  Should  the  affection  tend  to  assume 
the  diffuse  form,  as  shown  by  increasing  tympany  and  broaden- 
ing of  the  area  of  hyperaesthesia  and  rigidity,  absolute  starva- 
tion  is  indicated  for  at  least  24  hours  in  order  to  inhibit  per- 
istalsis. If  the  infection  spreads  in  spite  of  these  measures, 
drainage  through  the  vagina  may  be  considered.  The  latter 
procedure  is  indicated  at  an  early  date  in  peritonitis  from  ovarian 
infection  or  ruptured  ovarian  abscess,  or  infection  from  uteri 
which  are  not  so  large  as  to  be  abdominal  rather  than  pelvic 
organs.  Meantime  all  the  medical  measures  indicated  should 
be  continued,  as  drainage  is  only  one  factor  in  the  treatment,  but 
its  prompt  use  may  throttle  in  its  incipiency  what  might  other- 
wise prove  to  be  a  serious  infection. 

An  inflamed  appendix  situated  in  the  pelvis  should  be  treated 
by  early  removal  precisely  as  though  it  were  in  the  right  iliac 
fossa.  Overwhelming  general  peritonitis  is  so  universally  fatal, 
no  matter  what  the  treatment,  that  when  it  is  seen  late  in  its 
course  it  should  be  handled  purely  symptomatically.  Earlier, 
a  simple  drainage  operation  under  local  anaesthesia  is  of  some 
value,  and  if  the  inflammatory  process  is  in  the  diffuse  stage, 
not  having  reached  its  acme,  such  an  operation  may  be  curative. 

Chronic  Pelvic  Peritonitis. — The  great  majority  of  cases 
which  are  diagnosed  as  chronic  peritonitis  are  those  having  ''left- 
over" products  from  the  acute  form.  An  occasional  patient  is 
met  with  who  has  an  apparent  predilection  toward  the  forma- 
tion of  adhesions,  and  there  is  a  special  type  of  sclerosing  peri- 
tonitis the  etiology  of  which  is  wholly  unknown.  In  this  the 
primary  process  seems  to  be  in  the  mesentery,  cicatrices  gradu- 
ally extending  to  the  free  border  of  the  intestine  and  binding 
all  into  one  solid  mass  which  is  pierced  in  a  tortuous  manner  by 
the  intestinal  lumen.  Such  cases  are  not  often  correctly  diag- 
nosed and  are  more  likely  to  be  discovered  accidentally  during 


ACUTE   PELVIC  CELLULITIS  449 

the  course  of  an  operation  for  some  other  disease.  Careful 
separation  of  all  adhesions  seems  to  be  the  logical  treatment  with 
the  hope  that  if  they  re-form  they  will  be  less  troublesome  than 
in  their  original  location. 

Acute  Pelvic  Cellulitis. — All  chronic  pelvic  inflammations 
were  regarded  as  cases  of  pelvic  celluHtis  until  Lawson  Tait 
began  his  career  as  an  abdominal  surgeon  and  proved  that  what 
had  been  so  regarded  and  treated  really  was  salpingitis.  Fol- 
lowing this  demonstration  it  became  fashionable  to  look  upon 
all  pelvic  inflammation  as  intra-peritoneal.  This  position  is 
wholly  untenable,  as  both  acute  and  chronic  inflammation 
of  the  pelvic  cellular  tissue  are  of  frequent  occurrence. 

Acute  pelvic  cellulitis  almost  without  exception  is  due  to 
an  infected  injury  of  the  cervix  or  body  of  the  uterus.  Instru- 
mental dilatation  of  the  cervix  to  provide  room  for  the  removal 
of  retained  infected  products  of  conception  often  results  in 
acute  pelvic  cellulitis,  as  does  dilatation  with  intent  to  induce 
abortion.  Infection  of  the  cervix  after  a  full-term  labor  may 
also  result  in  acute  celluHtis.  For  some  reason  which  is  not 
clearly  understood,  the  onset  of  cellulitis  follows  at  a  compara- 
tively late  period  after  the  presumed  infection  has  taken  place. 

Symptoms,  Diagnosis  and  Clinical  Course. — In  a  patient  whose 
preceding  history  indicates  that  infection  of  the  cervix  or  uterus 
is  possible,  elevation  of  temperature,  rapid  pulse,  continuous 
moderate  pain,  and  vesical  or  rectal  tenesmus  should  lead  to  a 
suspicion  of  pelvic  cellulitis.  Upon  examining  a  patient  with 
acute  celluHtis  a  swelling  will  be  found  at  one  or  both  sides 
of  the  uterus,  this  sweUing  tending  to  encircle  the  cervix  Hke 
a  collar.  At  the  sides  of  the  uterus  the  swollen  tissue  depresses 
the  lateral  fornices  of  the  vagina  and  seems  much  closer  to 
the  examining  finger  than  it  does  in  salpingitis  or  ovarian 
abscess.  This  swelHng  extends  soHdly  to  the  pelvic  wall  and 
ultimately  may  run  far  up  over  the  pelvic  brim,  passing 
outward  between  the  layers  of  the  broad  Hgament  and  elevating 
29 


450  PELVIC  PERITONITIS,   PELVIC   CELLULITIS 

the  parietal  peritoneum  external  to  its  reflexion  onto  the  pelvic 
wall. 

The  characteristic  features  are  the  moderate  pain  (much  less 
than  in  peritonitis),  the  close  proximity  of  the  inflammatory 
mass  to  the  examining  finger,  and  its  extension  between  the 
bladder  and  cervix  anteriorly  exactly  as  one  would  expect  if 
the  anatomical  distribution  of  the  cellular  tissue  in  the  pelvis 
were  kept  in  mind.  This  inflammatory  exudate  may  undergo 
resolution,  it  may  be  riddled  by  the  formation  of  multiple  small 
abscesses,  or  one  large  abscess  may  develop  which  points  into 
the  vagina,  the  bladder,  the  rectum,  or  through  the  anterior 
abdominal  wall  just  above  the  inguinal  ligament.     Extension  of 


Fig.  223. — Location  of  exudate  in  pelvic  cellulitis.     {Redrawn  from  Montgomery.) 

infection  by  way  of  the  hilum  of  the  ovary  may  result  in  second- 
ary ovarian  abscess  and  peritonitis. 

Even  in  those  cases  in  which  resolution  finally  occurs,  the 
process  extends  over  a  protracted  period  with  alternating  remis- 
sion and  exacerbation  of  symptoms,  and  with  the  formation  of 
multiple  small  abscesses  a  most  annoying  and  long-drawn-out 
course  is  certain  to  ensue.  The  diagnosis  of  suppuration  is 
frequently  impossible,  or  if  it  is  suspected  the  location  of  the  pus 
is  uncertain  until  spontaneous  opening  into  the  bladder  or  rec- 
tum has  occurred,  when  a  definite  cystitis  or  proctitis  may  be 
added  to  the  original  trouble.  Patients  with  rather  acute  symp- 
toms are  more  likely  to  develop  free  suppuration,  the  evacuation 
of  the  abscess  resulting  in  early  cure. 

Treatment. — Were  the  anatomy  of  the  broad-ligament  bases 
less  complicated,  early  incision  and  drainage  through  the  vagina 


CHRONIC   PELVIC   CELLULITIS  45 1 

would  be  an  ideal  mode  of  treatment,  as  is  early  free  drainage  in 
infection  of  cellular  tissue  elsewhere.  Unfortunately,  the  risk  of 
opening  the  bladder  or  ureter,  or  of  damaging  the  uterine  artery 
in  an  inaccessible  location,  is  too  great  to  justify  operation  until 
pus  formation  with  softening  is  fairly  evident.  The  treatment 
at  an  early  stage,  therefore,  is  purely  palliative,  and  rest  in  bed 
until  all  the  symptoms  have  subsided  is  imperative.  Many 
patients  subject  themselves  to  unnecessary  risk  and  prolong 
their  suffering  many  weeks  by  getting  about  while  a  little  ele- 
vation of  temperature  persists.  In  a  mild  case  the  pain  is  so 
trivial  that  it  is  difficult  to  persuade  a  patient  of  the  necessity  for 
complete  rest,  but  treatment  is  futile  without  it.  Cathartics 
are  harmless  as  the  infection  is  extra-peritoneal,  and  very  long 
hot  douches  are  comforting.  Whether  they  are  of  any  definite 
value  is  open  to  question  but  the  probability  of  benefit  is  much 
greater  than  it  is  in  intra-peritoneal  inflammation.  Persistence 
of  symptoms  over  many  weeks  gives  rise  to  a  suspicion  of  pus 
formation,  and  repeated  examinations  should  be  made  to  ascer- 
tain whether  any  point  of  softening  is  present.  Localized  ex- 
tremie  tenderness  to  pressure,  or  oedema  over  a  local  area,  is 
sufficient  to  justify  an  exploratory  incision.  If  softening  occurs 
in  the  vaginal  vault  at  one  side  of  the  cervix,  a  small  incision 
should  be  made  at  this  point  and  a  sharp-nosed  haemostat  be 
used  to  tear  the  opening  wider  if  pus  is  found.  Visible  swelling 
above  the  inguinal  ligament  usually  means  that  an  abscess  has 
formed  which  should  be  opened  through  the  abdominal  wall 
without  invasion  of  the  peritoneal  cavity.  This  is  accomplished 
by  using  only  blunt  dissection  after  the  peritoneum  is  reached, 
and  stripping  it  back  from  the  pelvic  wall  until  the  inflammatory 
focus  is  entered. 

Chronic  Pelvic  Cellulitis. — Doubt  is  sometimes  expressed 
that  chronic  cellulitis  exists,  but  this  doubt  may  be  dissipated  by 
investigating  the  condition  of  the  broad- ligament  bases  in  cancer 
of  the  cervix,  cellulitis  with  fixation  being  an  accompaniment 
of  cervical  carcinoma  before  malignant  invasion  has  occurred. 


452  PELVIC  PERITONITIS,   PELVIC   CELLULITIS 

Contraction  of  the  cicatricial  tissue  in  one  broad  ligament, 
which  draws  the  uterus  toward  that  side  of  the  pelvic  cavity, 
practically  always  follows  an  acute  cellulitis. 

There  is  a  distinct  chronic  cellulitis  which  accompanies  old 
infected  cervical  lacerations,  and  its  results  may  be  palpated  as  a 
cicatrix  running  off  from  the  apex  of  the  tear.  Patients  having 
this  form  of  chronic  cellulitis  complain  frequently  of  pelvic  pain, 
and  are  as  frequently  thought  to  have  ''ovarian  disease" 
because  of  the  location  of  the  pain  and  tenderness. 

The  treatment  is  simple  and  consists  of  amputation  of  the 
cervix  to  the  infection  of  which  the  cellulitis  is  secondary.  Hot 
douches  and  tampons  alleviate  the  discomfort,  the  latter  acting 
by  maintaining  the  uterus  in  such  position  that  it  does  nbt  drag 
on  its  broad-ligament  attachments. 

POSTERIOR  VAGINAL   SECTION 

The  indications  for  vaginal  section,  for  exploration  and  for 
drainage,  have  been  given  in  the  sections  devoted  to  ovarian 
inflammation,  peritonitis,  and  ectopic  pregnancy.  When  men- 
tioned in  these  connections  incision  through  the  posterior  vaginal 
wall  is  referred  to,  but  it  is  quite  possible  to  open  and  explore 
the  -pelvis  through  an  opening  anterior  to  the  cervix,  that  is  be- 
tween it  and  the  bladder,  although  this  presents  no  special 
advantage  and  is  more  diflicult. 

One  of  the  advantages  of  posterior  vaginal  section  lies  in 
the  fact  that  it  can  be  done  under  local  anaesthesia  if  the 
patient  is  in  such  condition  that  a  general  anaesthetic  would  add 
materially  to  the  risks,  the  principal  discomfort  of  the  patient 
who  is  not  anaesthetized  being  due  to  such  traction  upon  the 
perineum  as  is  necessary  in  order  to  expose  the  vaginal  fornix. 

The  patient  is  placed  in  the  lithotomy  position  and  the 
same  aseptic  precautions  taken  as  would  be  the  case  if  the 
abdomen  were  to  be  opened  through  its  anterior  wall.  The 
perineum  is  well  retracted  and  the  vaginal  wall  behind  the 


POSTERIOR  VAGINAL  SECTION 


453 


cervix  picked  up  with  tenaculum  forceps  or  a  long  hgemostat. 
The, cervix  itself  is  not  drawn  upon,  as  no  more  certain  method 
could  be  adopted  for  tearing  adhesions  and  flooding  the  pelvis 
with  pus. 


Fig.  224. — Posterior  vaginal  section.     The  vaginal  wall  posterior  to  the  cervix 
is  picked  up  and  incised  transversely. 

The  fold  of  vaginal  wall  in  the  haemostat  is  drawn  down  and 
a  transverse  incision  made  squarely  across  this  fold  with 
scissors.  This  incision  should  be  from  3  to  5  cm.  long.  The 
connective  tissue  between  the  vaginal  wall  and  peritoneum  is 
pushed  aside  with  the  fingers  or  closed  scissors  until  the  peri- 


454 


PELVIC   PERITONITIS,   PELVIC   CELLULITIS 


toneum  is  exposed,  the  points  of  the  scissors  or  end  of  the  finger 
being  directed  upward  and  toward  the  cervix  in  order  to  avoid 
injury  to  the  rectum.  One  or  two  vessels  in  the  vaginal  wall 
may  spurt  vigorously  and  should  be  controlled  with  forceps. 
The  incision  is  now  opened  widely  by  drawing  on  its  anterior  and 


Fig.  225. — Posterior  vaginal  section.     The  peritoneum  is  exposed  and  may  be 
picked  up  and  incised  as  in  laparotomy  through  the  anterior  abdominal  wall. 


posterior  folds,  and  if  the  operation  is  a  formal  one  the  perito- 
neum is  picked  up  and  incised.  If  the  opening  is  only  for  drain- 
age, or  to  withdraw  the  vaginal  end  of  a  gauze  pack,  the  perito- 
neum is  torn  through  with  a  blunt  instrument. 


POSTERIOR  VAGINAL   SECTION  455 

Should  pus  or  blood  be  present  it  will  escape  at  once,  and 
the  disposition  to  cease  work  is  strong.  In  most  cases,  how- 
ever, in  which  vaginal  section  is  indicated  further  exploration 
with  the  finger  is  necessary.  If  the  operation  is  purely  explora- 
tory and  diagnostic,  as  in  ruptured  extra-uterine  pregnancy,  the 


Fig.  226. — Posterior  vaginal  section.     The  finger  introduced  for  exploration 

average  operator  will  do  well  to  insert  two  or  three  stitches  in 
the  vaginal  incision  and  proceed  to  open  the  abdomen  from  above, 
while  the  expert  will  possibly  be  able  to  remove  the  tube  through 
the  vagina.  If  the  incision  opens  a  well-walled-off  haematocele, 
the  insertion  of  a  drain  is  all  that  is  required. 


456 


PELVIC  PERITONITIS,   PELVIC   CELLULITIS 


In  pus  cases  all  instruments  are  withdrawn  from  the  vagina 
excepting  those  which  hold  the  incision  open,  and  the  finger  is 
introduced  to  note  the  condition  of  such  pelvic  structures  as 
can  be  palpated.     A  gonorrheal  pus  tube  should  not  be  broken 


Fig.  227. — Posterior  vaginal  section.     The  operation  completed.     Gauze  drain 

protruding. 


into  through  the  vaginal  incision,  since  its  evacuation  opens  a 
cavity  which  was  on  its  way  to  spontaneous  sterilization  and 
opening  it  is  likely  to  lead  to  a  tubo-vaginal  fistula.  Many 
failures  to  permanently  cure  pelvic  infection  are  due  to  neglect 


REFERENCES  457 

in  not  palpating  the  organ  originally  involved,  and  determining 
whether  salpingitis,  or  acute  oophoritis,  is  responsible  for  the 
suppuration.  In  the  former,  simple  drainage  of  the  pelvic  cav- 
ity is  all  that  is  needed;  in  the  latter,  not  only  must  the  pelvic 
cavity  be  drained  but  the  ovary  itself  should  be  perforated  with 
the  finger  or  a  blunt  instrument. 

Drainage  can  be  secured  by  any  method  which  will  keep  the 
lips  of  the  incision  apart  without  at  the  same  time  plugging  the 
opening.  In  haematocele,  and  in  early  infection  in  which  serum 
is  present,  a  fluffy  gauze  drain  is  sufficient.  In  pus  cases  drain- 
age is  best  accomplished  by  a  large  tube  which  is  introduced 
but  a  short  distance  into  the  abscess,  as  a  long  tube  may  rupture 
adhesions  and  open  the  general  peritoneal  cavity.  Difficulty 
is  always  experienced  in  keeping  the  tube  in  place  unless  it  is 
made  with  a  T  at  the  end,  but  a  stitch  of  non-absorbable 
material  passed  through  the  tube  and  one  lip  of  the  incision  is 
equally  efficient  if  a  T  tube  is  not  available.  The  tube  should 
extend  to  the  vulva  which  should  be  covered  by  a  large  lap- 
arotomy pad.  In  the  after-treatment  these  pads  should  be 
changed  as  often  as  the  necessities  of  the  case  demand,  and  the 
patient  should  not  be  catheterized  unless  absolutely  necessary 
on  account  of  the  risk  of  infecting  the  bladder. 

REFERENCES 

BANDLER,  S.  W.— Vaginal  Celiotomy.     Philadelphia,  1910. 

WATSON. — General  Peritonitis  in   Gynecological   and   Obstetrical  Practice. 

Canada  Prac.  &'  Review,  1913,  xxxviii,  85. 
FISHBEIN. — Contribution    to    the   Bacteriology   of   Peritonitis    with    Special 

Reference  to  Primary  Peritonitis.     A.  J.  M.  S.,  191 2,  cxliv,  502. 
HOMSTEIN. — Beitrage  zur  Kasuistik  der  gynakologischen  Peritonitis.     Arch. 

f.  Gyn.,  191 2,  xcvii,  114. 
ECHOLS. — Traumatic   Rupture   of   Pus   Tubes    Causing   Diffuse   Peritonitis. 

Surg.,  Gyn.  ^  Ohst.,  19 10,  xi,  589. 
VEIT. — tJber  die  operative  Behandlung  der  septischen  und  der  gonorrhoischen 

Peritonitis.     Monats.  f.  Geb.  iind  Gyn.,   191 2,  xxx\d;  Festschrift  dem,  vi; 

Internal.  Gyn.  Kong.,  83. 
GELINSKY. — Die  Gefahren,  Verhiitung    and    Behandlung    der    abdominalen 

Infektion.     u.  s.  w.     Arch.  f.  Klin.  Chirurg.,  1914,  ciii,  949. 


458  PELVIC   PERITONITIS,    PELVIC   CELLULITIS 

CREDE. — Antiseptische    Behandlung    der    Peritonitis.     Miinch    med.    Woch., 

1913,  Ix,  2117. 
BAUER. — Zur  Behandlung  der  acuten,  freien  eitrigen  Peritonitis,  mit  besonderer 

Riicksicht  auf  die  Frage  der  Primarnaht.     Arch.  f.  Klin.  Chirurg.,  191 1, 

xcvi,  938. 
KUHN. — Die  Zukerbehandlung  der  Bauchfellentziindung.     Arch.  Klin.  Chir., 

1911,  xcvi 
JUDD. — Postoperative  Treatment  of  General  Suppurative  Peritonitis.     Med. 

Rcc,  191 2,  Ixxxi,  10. 
MORIARTA,  D.  C. — Pelvic  Cellulitis.     Albany  Med.  Annals,  1913,  xxxiv,  543. 


CHAPTER  XV 

CONGENITAL  ANOMALIES 

A  brief  consideration  of  the  embryological  development  of 
the  female  genitalia  and  adjacent  parts  will  convince  one 
that  nearly  all,  if  not  all  the  anomalies,  are  due  to  arrested 
development. 

The  development  of  the  ovaries  from  the  genital  glands  of 
early  embryonic  life;  of  the  tubes,  uterus,  and  vagina,  by  fusion 
of  the  Miillerian  tubes;  of  the  vulva  from  the  genital  tubercle; 
and  the  bladder  and  urethra  from  the  allantois;  as  well  as  the 
early  embryonic  existence  of  a  cloaca  into  which  the  bladder, 
vagina,  and  rectum  open;  serves  to  explain  the  etiology  of  con- 
genital anomalies  by  an  arrest  of  development  before  the  com- 
plete evolution  of  the  adult  parts. 

Conditions  which  are  extremely  rare,  and  minute  distinctions 
between  types  of  the  same  general  deformities,  will  not  be 
touched  upon  as  they  are  of  academic  interest  only. 

THE  VULVA 

Hermaphroditism.^ — The  most  striking  developmental  defect 
about  the  vulva  is  that  associated  with  hermaphroditism. 
True  hermaphroditism,  that  is  the  association  of  both  male  and 
female  true  sex  organs  in  the  same  individual,  probably  does 
not  occur.  Pseudo-hermaphroditism,  in  which  the  external 
organs  apparently  belong  to  one  sex  while  the  true  sex  organs 
are  those  of  the  other,  is  fairly  common.  In  most  instances 
these  individuals  really  are  males  whose  external  organs  closely 
resemble  those  of  the  female  while  the  testicles  are  either  in 
the  inguinal  canal  or  abdomen.     Some  males,  who  really  are 

459 


460 


CONGENITAL   ANOMALIES 


only  hypospadiacs  or  cryptorchids,  are  regarded  as  females 
until  they  reach  the  age  of  puberty,  when  they  reveal  such  con- 
clusive male  secondary  sexual  characteristics  as  to  lead  to  a 
thorough  examination. 

A  description  of  the  most  striking  case  seen  by  the  author 
will  serve  as  an  example  to  illustrate  male  pseudo-hermaphro- 
ditism. 


Fig.  228. — Author's  case  of  a  male  pseudo-hermaphrodite. 

This  individual  always  had  been  regarded  as  a  girl  and  at  the 
age  of  seventeen  was  in  the  senior  class  in  high  school.  She  had 
known  of  a  small  inguinal  hernia  for  some  time,  and  on  returning 
from  school  one  day  the  hernia  came  down,  severe  pain  occurred, 
and  her  physician  was  unable  to  reduce  it  under  anaesthesia.  The 
patient  was  brought  to  the  hospital,  where  an  examination  con- 
firmed the  previous  diagnosis  of  strangulated  hernia.  Out  of 
respect  for  the  age  and  presumed  sex  of  the  patient,  the  external 


HERMAPHRODITISM  46 1 

genitals  were  kept  covered  during  the  examination  as  well  as 
the  preparation  for  operation. 

Under  anaesthesia  the  usual  incision  for  inguinal  hernia  was 
made,  and  considerable  free  fluid  was  found  in  the  sac  together 
with  a  loop  of  discolored  small  intestine,  whose  vitality  was  not 
seriously  impaired.  On  reducing  the  intestine  an  ovoid  body 
resembling  an  ovary  was  found  in  the  posterior  portion  of  the 
sac.  This  was  much  discolored,  apparently  gangrenous,  and 
also  seemed  densely  adherent  to  that  portion  of  the  sac  to  be 
removed,  so  that  no  hesitation  was  felt  in  removing  it  with  the 
sac.  The  patient  was  in  rather  serious  condition,  regurgitating 
intestinal  contents  at  intervals  and  taking  the  anaesthetic 
badly,  but  something  about  the  appearance  of  this  organ  led 
to  the  introduction  of  the  fingers  into  the  pelvic  cavity  in  an 
effort  to  find  either  the  tube  or  uterus,  both  of  which  were  ab- 
sent. The  other  inguinal  canal  contained  a  palpable  organ 
about  the  size  of  the  one  just  removed.  Examination  of  the 
external  genitalia  then  showed  a  hypospadiac  penis  3  cm.  in 
length,  with  the  urethra  at  its  base,  and  a  cleft  scrotum  with  a 
depression  in  the  mid-line,  i  cm.  in  depth,  which  might  easily 
be  mistaken  for  the  vaginal  orifice.  The  scrotal  hair  was  thick 
and  coarse,  and  neither  half  of  the  scrotum  was  larger  than  a 
well-developed  labium  majus. 

The  secondary  sexual  characteristics  were  masculine.  The 
breasts  were  flat,  the  arm.s  flat  and  muscular,  and  the  buttocks 
thin.  The  voice  alternated  between  the  high  pitched  voice  of 
a  child  and  the  low  pitch  of  an  adult  male,  and  in  fact  was  just 
"changing." 

Females  with  hypertrophy  of  the  clitoris  and  stenosis  or 
atresia  of  the  vagina  or  vulva  are  sometimes  thought  to  be 
female  hermaphrodites,  but  such  trifling  deviations  from  the 
normal  do  not  deserve  to  be  so  classified. 

The  most  imperative  consideration  in  pseudo-hermaphrodi- 
tism  is  to  determine  the  sex  of  the  individual  at  an  early  age, 
the  danger  of  allowing  a  male  hermaphrodite  of  the  type  above 


462  CONGENITAL  ANOMALIES 

described  to  mingle  with  girls  of  his  own  age  being  so  apparent 
as  scarcely  to  need  mentioning.  With  a  testicle  in  the  inguinal 
canal  the  task  is  easy;  if  both  are  retained  in  the  abdomen  it 
may  be  difhcult,  but  the  obviously  safe  course  is  to  dress  such 
individuals  as  males  until  the  contrary  can  be  proven. 

Persistence  of  the  embryonic  cloaca  through  failure  of  devel- 
opment of  the  recto-vaginal  septum  is  also  occasionally  ob- 
served. In  one  such  instance  seen  by  the  author,  the  rectum 
opened  by  a  large  orifice  just  within  the  vulvar  cleft,  but 
the  urethra  had  continued  on  to  perfect  development.  The 
menstrual  molimen  occurred,  but  without  menstrual  flow,  each 
period  being  punctuated  by  four  or  five  days  of  severe  bronchial 
asthma.  Aside  from  the  genital  organs  this  patient  was  a  per- 
fectly developed  female,  and  bimanual  rectal  examination  re- 
vealed the  presence  of  both  ovaries  but  complete  absence  of 
the  uterus  and  upper  portion  of  the  vagina. 

Anomalies  of  the  Hymen. — Anatomically,  the  hymen  is 
described  as  a  crescentic  membrane  guarding  the  vaginal  in- 
troitus.  Embryologically,  that  view  which  regards  the  hymen 
as  the  analogue  of  a  portion  of  the  male  corpus  spongiosum 
seems  to  be  borne  out  by  the  continuation  of  the  outer  edges 
of  the  hymen  upward  to  the  urethra  in  the  foetus  and  in  some 
young  infants.  The  very  severe  hemorrhage  which  occasion- 
ally takes  place  when  the  hymen  is  ruptured  could  thus  be 
explained  by  the  presence  of  erectile  tissue  in  its  structure. 

A  variety  of  shapes  and  forms  are  met  with,  but  none  are  of 
importance  excepting  complete  closure  of  the  membrane,  im- 
perforate hymen.  This  anomaly  is  not  likely  to  be  discovered 
until  after  puberty,  when  the  symptoms  of  menstruation  with- 
out external  discharge  lead  sooner  or  later  to  an  examination, 
possibly  not  until  several  years  have  elapsed  and  the  patient's 
abdomen  has  become  noticeably  enlarged.  Usually  there  is 
enough  pain  to  lead  to  an  examination  before  extreme  disten- 
sion of  the  genital  canal  has  taken  place,  but  the  ignorance  of 
young  girls  concerning  the  onset  of  menstruation  and  the  degree 


IMPERFORATE   HYMEN 


463 


of  discomfort  which  they  should  suffer  at  this  time  is  astounding. 
The  diagnosis  is  readily  made.  On  separating  the  labia  the 
hymen  is  found  bulging  from  the  pressure  within,  and  the  dark 
color  of  the  retained  menstrual  fluid  is  seen  through  the  thinned 
out  membrane.  If  the  condition  has  existed  for  many  months, 
the  vagina,  uterus,  and  tubes  are  distended  with  the  retained 


Fig.  229. — Double  vagina, 
the  longitudinal  septum  ending 
before  reaching  the  cervix. 


Fig.  230. — Double  vagina. 
Septum  as  it  appears  on  inspec- 
tion of  the  vulva. 


secretions,  the  uterus  and  vagina  forming  one  canal  as  they  do 
during  the  second  stage  of  labor.  The  distended  tubes  may  or 
may  not  communicate  with  the  uterus.  In  the  latter  event  the 
tubal  secretion  distends  them  unaided  by  reflux  from  the  uterus. 


THE  VAGINA 


The  congenital  vaginal  defect  most  frequently  encountered 
is  a  transverse  band  which  produces  stenosis  and  occasionally 


464  CONGENITAL  ANOMALIES 

complete  atresia.  The  occluded  membrane  generally  has  a 
small  opening  at  some  point  so  that  menstrual  fluid  is  not 
retained,  and  pregnancy  is  possible  if  this  band  is  sufficiently 
high  in  the  vagina  to  permit  coitus. 

Occasionally,  owing  to  complete  failure  of  development,  no 
vagina  at  all  can  be  found.  The  vulva  may  present  a  normal 
appearance,  but  the  anterior  rectal  and  posterior  bladder  walls 
are  completely  fused. 

The  double  vagina  also  is  not  so  very  rare.  In  these  patients 
absorption  of  the  wall  between  the  lower  ends  of  the  Miillerian 
tubes  has  not  taken  place.  The  uterus,  cervix,  and  vagina  may 
be  double,  or  the  septum  may  end  before  reaching  the  cervix, 
the  internal  genitalia  being  normal. 

One  Miillerian  tube  may  be  more  completely  developed  at  its 
lower  extremity  than  the  other,  so  that  one  vagina  may  be 
normal  while  the  other  is  small  and  imperfectly  developed,  and 
in  such  a  case  repeated  examinations  may  have  been  made  with- 
out detecting  the  abnormality.  If  the  septum  between  the  two 
halves  of  the  vagina  is  incomplete,  it  is  of  little  moment  aside 
from  the  certainty  of  its  injury  during  labor.  A  complete  sep- 
tum is  of  more  interest,  as  it  frequently  points  to  abnormalities 
of  the  cervix  and  uterus. 

THE    UTERUS    AND    TUBES 

Fusion  of  the  Mullerian  tubes  to  form  the  uterus  may  com- 
pletely fail,  when  two  uteri  are  found.  More  frequently,  two 
bodies  and  fundi  are  present,  but  partial  fusion  has  occurred 
at  the  cervix,  so  that  there  is  presented  a  single  cervix  with 
two  canals  which  branch  at  the  level  of  the  internal  orifice, 
while  superior  to  the  cervix  are  two  complete  but  imperfect 
bodies.  This  division  may  take  place  at  a  still  higher  level,  so 
that  but  one  body  is  presented  which  is  divided  longitudinally 
by  a  septum  while  the  fundus  is  split.  The  ducts  may  fuse 
normally  and  absorption  of  the  septum  fail.     In  this  event  the 


SEPTATE   UTERUS 


465 


cervix,  body,  and  fundus  form  one  uterus,  but  with  a  complete 
longitudinal  septum.     As  in  the  vagina,  when  the  septum  is 


Fig,  231. — The  Miillerian  tubes  have  completely  failed  to  fuse.     There  is  a 

double  uterus  and  vagina. 

incomplete  the  hiatus  is  at  the  superior  end,  so  that  a  septum  in 
the  lower  half  of  the  vagina  may  be  present,  the  upper  vagina, 
30 


466 


CONGENITAL  ANOMALIES 


cervix,  and  uterus  being  normal;  or  the  septum  may  extend  to 
and  through  the  cervix,  the  body  and  fundus  being  normal; 
or  the  vagina,  cervix,  and  body  may  be  divided,  the  fundal 
septum  being  incomplete 

Occasionally  one  Miillerian  duct  atrophies  or  entirely  fails 
to  develop,  when  a  one-horned  uterus  with  but  one  uterine  tube 
is  found. 

Both  tubes  may  be  missing — a  rare  occurrence — or  one  may 
be  normal  and  the  other  absent,  as  in  the  unicornate  uterus 


Fig.  232. — Double  vagina  and  cervix.     Uterus  Bicornis,     The  Miillerian  tubes 
have  not  met  at  the  fundus.     Split  fundus. 

mentioned  above.  One  tube  may  be  normal  and  the  other 
rudimentary,  or  a  tube  may  present  more  than  one  abdominal 
ostium. 

THE    OVARIES 

The  ovaries  are  developed  from  the  primitive  genital  ridge 
and    not   from    the    Miillerian    tubes.     They   therefore   may 


TREATMENT  OE  IMPERFORATE  HYMEN         467 

present  anomalies  when  the  other  genital  organs  are  perfectly 
normal,  or  the  uterus  and  vagina  may  be  missing,  but  the 
ovaries  be  both  present  and  functionating.  The  ovaries 
may  be  small,  imperfectly  developed,  or  absent  when  the 
other  organs  are  present,  but  under  such  circumstances  com- 
plete development  does  not  take  place  as  the  ovarian  secre- 
tion seems  to  be  necessary  in  order  to  secure  adult  development 
and  function.  The  presence  of  accessory  ovaries  often  has  been 
assumed  in  order  to  explain  menstruation  and  conception  after 
double  ovariotomy.  The  actual  occurrence  of  accessory  ovar- 
ies is  practically  unknown  however,  the  continuation  of  normal 
function  having  been  due  to  incomplete  removal  of  one  or  both 
organs. 

The  fundamental  relationship  which  exists  between  the  pitui- 
tary body,  thyroid,  adrenals,  and  ovaries  has  not  been  worked 
out  in  its  entirety,  but  that  there  is  some  intimate  connection 
between  the  functions  and  secretions  of  these  organs  cannot  be 
questioned.  It  is  certain  that  the  complete  development  of 
some  of  them  is  contingent  upon  the  others  being  present  and 
functionating,  and  the  whole  matter  is  a  peculiarly  fascinating 
subject  for  speculation. 

OPERATIONS  FOR  GENITAL  ATRESIA 

Imperforate  Hymen. — If  an  imperforate  hymen  is  discovered 
within  a  few  months  after  puberty,  at  a  time  when  nothing  but 
the  vagina  is  distended  by  the  retained  secretions,  operation  for 
its  relief  is  very  simple  and  consists  of  a  -{—shaped  incision 
through  the  center  of  the  hymen.  This  should  be  made  under 
aseptic  precautions,  and  asepsis  should  be  maintained  until 
the  complete  discharge  of  that  portion  of  the  blood  which  is 
adherent  to  the  vaginal  walls. 

The  same  operation  suffices  when  the  uterus  also  is  distended 
with  dammed  up  secretions,  but  the  risk  of  infection  is  consid- 
erable because  it  is  impossible  to  remove  all  the  adherent  blood 


468  CONGENITAL   ANOMALIES 

and  mucus,  and  decomposition  occurs  with  great  facility. 
Should  infection  be  added  to  the  sapraemia  caused  by  the  absorp- 
tion of  the  products  of  decomposition  the  outcome  may  be  very 
serious.  After  incising  the  hymen,  the  utero-vaginal  canal 
should  be  irrigated  and  gently  sponged  until  it  is  as  free  from 
debris  as  possible.  It  is  then  thoroughly  dried  and  lightly 
packed  with  iodoform  gauze  which  should  be  allowed  to  remain 
for  several  days  unless  evidence  of  sapraemia  necessitates  its 
earlier  removal.  When  the  gauze  is  withdrawn  the  utero-vag- 
inal cavity  is  again  irrigated  and  repacked. 

In  long-standing  cases,  in  which  the  tubes  also  are  distended 
with  blood,  it  is  a  serious  question  whether  the  abdomen  should 
not  be  opened  and  the  tubes  removed.  On  the  whole,  however, 
it  seems  better  to  watch  such  patients  carefully  after  evacuating 
the  contents  of  the  uterus  and  vagina,  but  to  open  the  abdomen 
immediately  upon  the  slightest  evidence  of  peritoneal  irritation. 
By  following  this  plan  tubes  will  not  be  sacrificed  which  might 
recover,  and  at  the  same  time  disastrous  infection  of  the  peri- 
toneal cavity  can  be  forestalled. 

Transverse  bands  and  septa  in  the  vagina  may  require  cutting 
in  order  that  coitus  may  take  place.  If  pregnancy  occurs  these 
bands  should  be  removed  early  in  gestation  as  they  may  be 
sufficiently  resistant  to  tear  the  vaginal  wall  deeply  during 
labor.  Usually  such  operations  are  extremely  simple  and  con- 
sist of  severing  the  band  and  ligaturing  or  suturing  any  bleeding 
points.  Those  diaphragms  which  are  nearly  complete  are  much 
more  difficult  to  manage  as  they  are  sometimes  very  thick  and 
so  draw  the  lateral  vaginal  walls,  bladder,  and  rectum  toward  a 
common  point,  that  cutting  blindly  may  open  the  lateral  plexus 
of  vaginal  veins  or  one  of  the  viscera. 

The  patient  should  be  anaesthetized  and  the  dissection  made 
in  a  slow  painstaking  manner.  Even  after  a  liberal  opening  is 
formed,  cicatricial  contraction  may  again  result  in  complete 
occlusion  unless  the  orifice  is  dilated  frequently  and  over  a  pro- 
longed period. 


SURGICAL   TREATMENT  469 

Septa  running  longitudinally  do  not  require  surgical  inter- 
ference unless  pregnancy  occurs.  In  that  event  it  is  safer  to 
split  the  septum  longitudinally  than  to  allow  it  to  remain  and 
undergo  injury  at  the  time  of  labor,  with  the  risk  of  subsequent 
sloughing.  Complete  absence  of  the  vagina  is  so  frequently 
associated  with  absence  of  the  uterus  that  treatment  is  not  often 
demanded.  Occasionally  a  patient  with  such  a  deformity 
marries,  when  the  exigency  of  circumstances  may  render  the 
formation  of  a  vagina  necessary.  The  operation  required  for 
this  purpose  should  not  be  undertaken  by  one  who  is  not  a  com- 
plete master  of  surgery,  and  with  all  the  ingenuity  available  it  is 
likely  to  be  unsuccessful.  Without  entering  into  descriptions 
which  are  not  suitable  for  a  work  of  this  character,  it  may  be 
stated  briefly  that  two  methods  are  available  after  a  tunnel  has 
been  formed  midway  between  the  rectum  and  bladder.  The 
formation  of  this  canal  or  tunnel  requires  a  laborious  bloody 
dissection,  and  must  be  followed  by  the  adjustment  of  a  suitable 
lining.  For  this  purpose  flaps  of  skin  from  the  labia  and  adja- 
cent parts  can  be  utilized,  but  cicatricial  contraction  unfortu- 
nately sometimes  nullifies  the  entire  operation.  Transplanta- 
tion of  a  loop  of  small  intestine,  after  the  method  advised  by 
Baldwin,  is  more  likely  to  prove  a  permanent  success  than  the 
adjustment  of  skin  flaps,  but  the  operation  is  both  difficult  and 
dangerous. 

Atresia  confined  to  the  lower  portion  of  the  cervix  is  readily 
overcome  by  amputation  of  the  cervix  and  transplantation  of 
vaginal  flaps  by  the  Schroeder  method. 

The  double  uterus  and  the  uterus  with  a  septum  rarely  de- 
mand treatment,  the  most  important  consideration  being  their 
recognition. 

Pregnancy  in  the  septate  uterus  seems  for  some  reason  to  have 
an  unusual  fatality  attached  to  it,  possibly  because  injury  to  the 
septum  so  lowers  its  vitality  that  sloughing  and  infection  take 
place. 


470  CONGENITAL  ANOMALIES 

REFERENCES 

HART,  D.  BERRY.— On  the  Atypical  Male  and  Female  Sexensemble.     Edin. 

M.  J.,  1914,  xiii,  295. 
THOMA. — Zur  Atiologie  der  Gynatresien      Monats.  f.  Geb.  und  Gyn.,  1913, 

xxxviii,  745. 
ARTZ. — Zur    Kenntnis    des    "fraglichen    Geschlechtes."     Wien.    klin.    Woch., 

1912,  XXV,  232. 

NEUMANN. — Zur   Kasuistik   der  Missbildungen   der  Weiblichen   Genitalien. 

Zentralb.  f.  Gyn.,  1907,  xxxi,  1621. 
EDITORIAL. — Hermaphroditism.     Brit.  Med.  J.,  191 1,  ii,  694. 
GUDERNATSCK. — Hermaphroditismus  Verus  in  Man.     Am.  J.  Anat.,  19 10- 

II,  xi,  267. 
KUSTNER. — Pseudohermaphroditismus  femininus  externus.     Zeitsch.  /.  Geh. 

und  Gyn.,  19 13,  Ixxiii,  816. 
KLAATSCH. — Das  Problem  des  menschlichen  Hymen.     Monats.  f.  Geh.  und 

Gyn.,  1914,  xl,  332. 
ANDREWS,  H.  R.— Two  Cases  of  Retention  of  Menses  in  Which  the  Peritoneal 

Cavity  Contained  Free  Blood.  /.  Obst.  b°  Gyn.,  But..  Emp.,  1911,  xix,  521. 
POZZI. — Absence  congenitale  der  vagin.  Societe  De  Chirur.,  1911,  xxxvii,  731. 
GEMMELL  AND  PATTERSON.— Duplication  of  Bladder,   Uterus,  Vagina, 

and  Vulva,  etc.     /.  Obst.  &°  Gyn.,  Brit.  Emp.,  1913,  xxiii,  25. 
STRATZ. — Zur  Entwicklung  der  Form  und  Lage  des  Uterus  und  seiner  Liga- 

mente.     Zeitsch.  f.  Geb.  und  Gyn.,  191 2,  Ixxii,  i. 
KERMANNER. — Die  Fehler  in  der  Verschmelzung  der  JSIiillerschen  Gange. 

Zeitsch.  f.  Geb.  und  Gyn.,  1912,  Ixxii,  724. 
ROSENSTEIN. — Uber  Spaltuterus  und  seine  Genese.     Monats.  /.  Geb.  und  Gyn., 

1913,  xxxviii,  71. 

ASCHNER. — Ueber  die  Beziehungen  Zwischer  Hypophysis  und  Genitale.     Arch. 

f.  Gyn.,  191 2,  xcvii,  200. 
HOFFMAN.— A  Malformation  of  the  Fallopian  Tube.     Surg.,  Gyn.  &•  Obst., 

191 2,  XV,  680. 
KERR. — Operative  Treatment  for  Malformation  of  Uterus  and  Vagina.     Surg., 

Gyn.  C5°  Obst.,  19 14,  xviii,  621. 
GRAVES. — Operative  Treatment  of  Atresia  of  the  Vagina.     Bost.  M.  &*  S.  J., 

1910,  clxiii,  753. 
ZALEWSKI. — Doppelmissbildungen    der    weiblichen    Genitalsphare   und   ihre 

Folgen  fur  die  (ieburt.     Arch.  f.  Gyn.,  1914,  cii,  189. 
STOECKEL. — tJber  die  Bildung  einer  kunstlichen  Vagina.     Zentralb.  f.  Gyn., 

191 2,  xxxvi,  7. 
STEWART. — Formation  of  an  Artificial  Vagina  by  Intestinal  Transplantation. 

Annals  Surg.,  1913,  Ivii,  210. 
BALDWIN. — Artificial    Vagina    by    Intestinal    Transplantation.     Med.    Rec, 

1912,  Ixxxii,  1170. 


CHAPTER  XVI 

STERILITY.    GONORRHEA.    THE      TREATMENT      OF 
MENSTRUAL  DISORDERS 

STERILITY 

The  exact  period  through  which  a  woman  who  indulges  in 
regular  intercourse  must  remain  unimpregnated  before  sterihty 
can  be  assumed  is  unknown,  but  for  practical  purposes  two  years 
of  married  life  without  pregnancy,  unless  artificial  means  for 
preventing  conception  have  been  used,  means  that  the  proba- 
bility of  pregnancy  is  slight. 

Etiology. — It  is  evident  that  sterility  in  the  female  may  be 
dependent  upon: 

1.  Anything  which  interferes  with  successful  coitus. 

2.  Anything  which  prevents  the  transmission  of  living  sper- 
matozoa from  the  vagina  to  the  ovule. 

3.  A  defect  in  the  ovule  which  interferes  with  its  successful 
union  with  the  spermatozoid. 

4.  Some  condition  which  will  not  allow  the  impregnated  ovule 
to  be  transmitted  to  the  uterus  or, 

5.  Some  condition  which  prevents  implantation  and  retention 
of  the  fecundated  ovule  in  the  uterus. 

Successful  coitus  may  be  prevented  by  imperforate  hymen, 
stenosis  of  the  vulva  or  vagina,  or  vaginismus.  In  the  absence 
of  complete  atresia  spermatozoa  deposited  upon  the  vulva  can 
make  their  way  into  the  vagina  and  thence  into  the  uterus,  but 
the  probability  of  pregnancy  is  enormously  lessened  if  they  are 
not  deposited  directly  in  the  posterior  vaginal  fornix.  Sper- 
matozoa penetrate  the  uterus  by  means  of  their  own  automatic 
form  of  locomotion,  and  their  presence  alive  and  active  in  the 

471 


472  STERILITY 

internal  genitalia  has  been  demonstrated  for  days  after  coitus. 
A  diseased  condition  of  tRe  vagina,  cervix,  uterus,  or  tubes, 
which  destroys  the  life  or  inhibits  the  mobility  of  the  spermato- 
zoa will  prevent  impregnation,  as  will  any  mechanical  impedi- 
ment to  their  transmission  to  the  outer  end  of  the  tube. 

Acids  in  very  weak  dilution  are  destructive  to  spermatozoids 
and  it  is  likely  that  many  other  toxic  substances,  even  in  minute 
quantities,  act  in  a  similar  manner  so  that  hyperacidity  of  the 
vaginal  secretions,  vaginitis  with  pus  formation,  endocervicitis, 
endometritis,  and  salpingitis,  may  by  their  toxic  discharges 
cause  the  death  of  the  sperm  cell  and  thus  prevent  conception 
aside  from  any  mechanical  interference. 

Acute  anteflexion  of  the  cervix  and  pronounced  retroversion 
of  the  body  of  the  uterus  act  similarly,  by  removing  the  cervix 
sufficiently  far  from  the  posterior  vaginal  cul-de-sac  so  that  the 
discharge  from  a  trivial  vaginitis  may  destroy  the  spermatozoa 
before  they  have  succeeded  in  effecting  an  entrance  into  the 
uterus. 

It  is  very  doubtful  whether  cervical  stenosis,  short  of  actual 
atresia,  is  alone  capable  of  producing  sterility,  as  the  sperm  cell 
certainly  can  penetrate  any  orifice  sufficiently  large  to  permit 
the  outflow  of  menstrual  blood,  but  it  is  conceivable  that  a 
combination  of  cervical  stenosis  and  a  tight-fitting  plug  of 
mucus  might  prevent  the  entrance  of  spermatozoa. 

Any  mechanical  impediment  in  the  uterus  itself  is  improbable, 
but  from  the  uterine  end  of  the  tube  to  its  fimbriated  extremity  a 
minute  lesion  is  capable  of  producing  occlusion  and  so  prevent- 
ing conception.  One  diseased  tube  alone  cannot  be  responsible 
for  sterility,  but  tubal  disease  is  so  common  and  so  universally 
bilateral  that  one  is  surprised  that  sterility  is  not  far  more  fre- 
quent than  it  is,  a  preceding  salpingitis  likely  being  responsible 
for  more  cases  of  sterility  than  all  other  causes  combined. 

But  little  is  actually  known  of  those  causes  which  might  lead 
to  imperfect  ovules,  but  it  can  be  surmised  that  they  are  many. 
In  addition  to  discharging  imperfect  ovules  the  ovary  may  be  the 


ETIOLOGY  473 

subject  of  tumors,  adhesions,  or  a  thickened  cortex,  any  of  which 
might  interfere  with  ovulation  by  preventing  the  discharge  of 
ripened  ovules  at  the  proper  period  of  their  development,  pos- 
sibly retaining  them  indefinitely  within  a  distended  vesicular 
follicle. 

Granting  that  the  ovule  and  spermatozoid  have  met,  the 
theoretical  conception  of  fecundity  thus  having  been  estab- 
lished, clinical  sterility  may  yet  be  brought  about  if  the  impreg- 
nated ovule  fails  to  pass  through  the  tube,  become  implanted  in 
the  uterus,  and  inhibit  at  least  one  menstrual  period.  A  tube 
which  allows  passage  to  the  spermatozoid  may  be  too  narrow  to 
allow  the  passage  of  a  fecundated  ovule,  in  which  event  it  may 
die,  or  lodge  in  the  tube  and  be  the  direct  cause  of  tubal  preg- 
nancy. The  fecundated  ovule  may  enter  the  uterus,  but,  owing 
to  some  disease  of  the  uterine  mucosa,  fail  to  implant  itself, 
or  it  may  become  implanted  and  cast  off  at  the  next  menstrual 
period. 

From  clinical  observation  only,  it  has  appeared  to  the  author 
that  the  last-mentioned  possibility  is  responsible  for  no  inconsid- 
erable number  of  cases  of  apparent  sterility,  many  sterile  women 
having  now  and  then  a  period  somewhat  delayed,  finally  men- 
struating rather  profusely  and  with  more  than  the  ordinary 
amount  of  pain.  If  this  view  is  correct,  such  patients  actually 
are  not  sterile,  but  on  the  contrary  are  the  victims  of  menstrual 
abortion. 

Interstitial  and  glandular  endometritis  may  produce  sterility 
through  the  ovum  failing  to  become  imbedded  in  the  diseased 
mucosa.  Fibroid  tumors  fortunately  induce  such  a  degree  of 
endometritis  as  to  prevent  conception  in  a  large  proportion  of 
cases,  and  any  disease  of  the  uterus  which  leads  to  the  condition 
termed  ''hemorrhagic  endometritis"  is  usually  incompatible 
with  pregnancy.  It  is  in  this  way  that  marked  displacement, 
frequent  coitus,  and  other  causes  of  repeated  pelvic  congestion 
sometimes  operate  to  induce  sterility. 

Contrary  to  a  widely  held  opinion,  neither  orgasm  nor  sexual 


474  STERILITY 

excitement  on  the  part  of  the  female  is  necessary  to  impregnation, 
the  latter  having  taken  place  when  the  woman  was  unconscious, 
but  it  is  likely  that  fecundation  is  rendered  more  probable  by  the 
flooding  of  the  vagina  with  alkahne  mucus  which  is  induced  by 
sexual  excitement. 

The  role  played  in  the  production  of  sterility  by  general  dis- 
eases such  as  syphilis  is  undoubtedly  of  considerable  moment. 
Syphilis  is  known  to  be  one  of  the  very  common  causes  of  abor- 
tion, miscarriage,  and  premature  labor,  and  it  is  not  unlikely 
that  it  may  inflict  sufficient  damage  upon  the  ovule  to  prevent 
conception. 

Syphilis  of  the  endometrium  may  prevent  implantation  of  the 
ovum  or  cause  its  discharge  at  so  early  a  date  that  pregnancy 
was  not  suspected. 

Treatment  of  Sterility. — It  should  be  remembered  that  not  all 
instances  of  presumed  sterility  are  the  fault  of  the  female,  many 
cases  of  male  sterihty  being  due  to  congenital  defects,  double 
epididymitis,  and  damaged  spermatozoa  by  reason  of  gonorrheal 
urethritis  and  prostatitis. 

In  the  female,  sterility  whose  origin  is  known  obviously  may 
be  curable  or  incurable,  and  the  same  can  be  said  of  sterihty 
whose  cause  is  surmised  only. 

The  plain  course  in  an  individual  case  is  to  remove  any  re- 
movable obstacle  to  conception,  but  even  then  many  instances 
will  remain  in  which  the  patient  remains  sterile  without  apparent 
reason. 

Vaginismus,  atresia  of  the  vulva  and  vagina,  and  stenosis  of 
the  cervix,  should  be  overcome  by  the  methods  outHned. 

Hyperacidity  of  the  vaginal  secretions,  vaginitis,  endocer- 
vicitis,  and  endometritis,  are  all  amenable  to  treatment,  as  are 
sharp  cervical  anteflexion  and  marked  retroversion.  Specific 
salpingitis  cannot  be  so  treated  as  to  permit  of  future  pregnancy 
in  any  but  the  most  limited  number  of  cases,  and  conservative 
operations  upon  occluded  tubes  more  frequently  lead  to  second- 
ary operation  than  to  future  conception. 


TREATMENT  475 

Imperfectly  developed  ovaries  and  disorders  of  the  ovule  it- 
self can  be  imagined  only,  and  if  our  conception  of  the  cause  is 
correct,  nothing  is  to  be  accomplished  by  treatment  unless  the 
patient  is  syphihtic. 

Women  suffering  from  dysmenorrhea  with  a  scanty  flow  from 
an  infantile  uterus,  may  in  the  future  be  benefited  by  knowledge 
derived  from  researches  into  the  functions  of  the  pituitary  and 
thyroid,  but  at  present  we  know  too  little  to  dogmatize. 

There  remains  a  fair  number  of  women  who  either  do  not 
become  pregnant  at  all  or  who  abort  at  the  next  menstrual 
period,  whose  past  history  is  clear  so  far  as  infection  is  concerned, 
who  menstruate  normally,  and  in  whom  examination  reveals 
neither  congenital  anomaly,  displacement,  nor  disease.  It  is 
these  patients  who  provide  an  excuse  for  a  thorough  dilatation 
of  the  cervix  with  sharp  curettage  of  the  uterus,  followed  by  a 
prolonged  period  of  weak  alkaline  douches,  and  they  provide 
this  excuse  because  operation  is  successful  in  a  very  moderate 
percentage  of  cases.  A  cure  should  never  be  promised,  but  if 
the  patient  desires  everything  done  which  is  possible  operation 
is  indicated  in  the  absence  both  of  the  history  and  physical 
evidence  of  preceding  inflammatory  disease. 

The  use  of  the  intra-uterine  stem  pessary  as  a  cure  for  dys- 
menorrhea and  sterility  has  recently  been  revived,  but  it  seems 
to  succeed  best  in  the  hands  of  those  who  are  responsible  for  its 
rescue  from  oblivion. 

Syphilis  can  be  so  treated  as  to  overcome  the  disposition  to 
repeated  abortion,  and  anti-syphilitic  treatment  may  remove  an 
otherwise  inexplicable  sterility. 

The  other  general  diseases  which  cause  sterility  should  be 
treated  on  their  merits,  but  not  many  of  them  are  amenable  to 
any  form  of  treatment. 

GONORRHEA 

Under  appropriate  headings  there  have  been  described  the 
inflammatory  processes  which  are  produced  by  the  gonococcus 


476  GONORRHEA 

of  Neisser.  Only  a  brief  resume  of  the  etiology,  life  history, 
clinical  course,  diagnosis,  and  treatment  of  gonorrhea  as  a  whole 
will  therefore  be  undertaken  at  this  time. 

Gonorrhea  of  the  sexual  organs  is  rarely  acquired  by  the  adult 
in  any  way  other  than  sexual  intercourse,  although  there  are 
well-authenticated  instances  of  its  acquisition  by  the  use  of 
infected  instruments,  douche  bags,  etc.  Vulvo-vaginal  gonor- 
rhea in  infants  and  young  children  seems  to  partake  more  of  the 
nature  of  a  contagious  than  an  infectious  disease.  It  is,  of  course, 
sometimes  acquired  by  sexual  contact,  but  bathing  and  handUng 
by  infected  nurses,  and  conveyance  of  the  disease  from  one  child 
to  another  in  a  fashion  that  seems  almost  uncanny  results  at 
times  in  virulent  epidemics  in  institutions.  When  this  takes 
place  the  most  extreme  measures  may  not  stamp  it  out  in  the 
infected,  and  all  known  precautions  fail  to  prevent  the  incidence 
of  new  infections. 

Although  his  stand  may  seem  extreme,  it  is  the  belief  of  the 
author  that  once  gonorrhea  is  acquired  by  any  individual,  infant 
or  adult,  it  never  is  completely  eradicated. 

The  clinical  course  of  gonorrhea  is  dependent  upon  the  viru- 
lence of  the  infection  and  the  organs  involved,  and  to  a  very  great 
degree  is  separable  into  two  classes,  acute  and  chronic,  each  of 
these  again  being  divisible  into  gonorrhea  of  those  structures 
external  to  the  internal  uterine  orifice,  and  gonorrhea  of  those 
organs  above  the  internal  uterine  orifice. 

Again,  while  gonorrhea  affects  mucous  surfaces  almost  exclu- 
sively it  may  invade  serous  membranes  as  a  gonorrheal  peri- 
tonitis, pleuritis,  or  arthritis. 

The  symptoms  of  acute  gonorrhea  are  those  of  an  acute  puru- 
lent inflammation  of  the  surfaces  invaded,  and  as  above  stated, 
they  are  of  two  widely  different  types  dependent  upon  whether 
or  not  the  infection  extends  above  the  internal  uterine  orifice. 
The  smarting  and  burning  of  acute  specific  urethritis  is  well 
understood;  invasion  of  the  Bartholinian  glands  give  rise  to 
acute  Bartholinitis  which  frequently  ends  in  abscess  formation; 


ACUTE   AND   CHRONIC  477 

gonorrheal  proctitis  causes  burning  about  the  anus  with  frequent 
painful  efforts  at  defecation.  Gonorrheal  vaginitis  in  the  adult 
is  not  often  seen,  the  next  step  higher  being  taken  as  gonorrhea 
of  the  fornix  of  the  vagina  and  mucosa  of  the  cervical  canal.  In 
acute  gonorrhea  these  are  all  accompanied  by  a  discharge  of  the 
typical  iodoform  yellow,  irritating  pus,  in  which  the  diplococcus 
of  Neisser  is  found  both  free  and  in  the  pus  cells. 

In  the  course  of  time,  and  either  with  or  without  treatment, 
this  merges  gradually  into  the  chronic  or  latent  form,  in  which 
there  usually  is  a  trivial  sero-purulent  urethral  discharge  to  be 
obtained  by  stripping,  or  a  drop  may  be  expressed  from  the  para- 
urethral ducts.  A  little  reddened  spot  marks  the  openings 
of  the  Bartholinian  ducts,  and  the  glands  themselves  may  give 
evidence  of  preceding  inflammation  by  the  formation  of  cysts, 
chronic  abscesses,  or  palpable  thickening.  Chronic  or  latent 
infection  of  the  cervix  gives  rise  to  a  ropy  mucopurulent  dis- 
charge, with  or  without  erosion  of  the  vaginal  face  of  the  cervix, 
erosion  however  being  a  usual  concomitant  of  gonorrheal  endo- 
cervicitis.  It  must  be  remembered  that  the  latent  or  chronic 
form  of  gonorrhea  of  the  lower  genitalia  may  be  such  from  the 
beginning,  and  that  a  definite  history  of  acute  disease  is  not  at 
all  necessary  to  establish  a  diagnosis  of  chronic  gonorrhea. 

It  has  seemed  to  the  author  that  this  form  most  commonly  is 
caused  by  gleet  in  the  male,  and  that  women  who  marry  men 
presumptively  ''cured"  of  their  gonorrhea  of  years  before  are 
most  likely  to  be  its  victims. 

In  the  discharge  from  any  of  these  locaHties  the  gonococcus 
sometimes  is  demonstrable  as  the  typical  intracellular  diplo- 
coccus, while  in  other  cases  of  known  gonorrheal  origin  it  is 
never  found. 

In  the  chronic  or  latent  form,  therefore,  the  presence  of  the 
gonococcus  is  indubitable  evidence  of  infection;  its  absence 
means  nothing. 

There  are  times,  too,  when  patients  at  this  stage  of  infection 
may  convey  it  to  others,  and  times  when  the  infection  seems 


478  GONORRHEA 

innocuous,  but  altogether  it  persists  indefinitely,  and  without 
a  doubt  gives  rise  to  ophthalmia  neonatorum  in  the  new-born 
infants  of  such  patients,  while  after  labor  it  is  the  source  of  many 
otherwise  inexplicable  cases  of  puerperal  infection.  Whether 
the  gonococcus  can  enter  the  blood  stream  and  cause  pleurisy, 
arthritis,  and  periostitis,  if  the  original  infection  has  not 
extended  beyond  the  internal  os,  is  uncertain. 

The  life  history  of  acute  gonorrhea  which  has  extended  above 
the  internal  uterine  orifice  is  much  more  definitely  established. 

Acute  endometritis  of  the  body  of  the  uterus,  followed  almost 
immediately  by  acute  salpingitis,  is  the  usual  outcome.  Here 
the  results  are  beyond  the  reach  of  medication,  and  the  inflamma- 
tion tends  to  remain  localized  while  the  gonococci  die  out  in  the 
uterus  and  tubes. 

The  gonococcus  is  rarely  found  in  the  uterine  mucosa  after 
the  subsidence  of  acute  symptoms,  and  never  is  found  in  sealed 
tubes  for  more  than  a  few  months  after  the  primary  salpingitis 
has  taken  place. 

The  brunt  of  the  inflammatory  process  is  borne  by  the  outer 
extremity  of  the  tube,  the  uterine  end  frequently  appearing  to 
be  normal,  and  recurrent  salpingitis  is  not  to  be  explained  by 
a  lighting  up  of  the  tubal  inflammation,  but  rather  by  recurrent 
endometritis  and  re-infection  of  the  uterine  end  of  the  tube. 

Those  cases  of  salpingitis  which  have  their  origin  in  acute 
gonorrhea  are  acute  and  brusque  in  accordance  with  their  acute 
source,  while  those  which  develop  from  the  more  slow  going 
latent  form  may  be  so  mild  that  the  symptoms  are  almost 
entirely  overlooked. 

Even  in  the  most  acute  form  of  gonorrheal  vulvo-vaginitis  in 
infants  the  inflammation  but  rarely  extends  into  the  uterine 
body,  and  gonorrheal  salpingitis  and  peritonitis  in  infants  are 
so  rare  that  but  an  occasional  case  is  recorded  in  the  literature. 

The  diagnosis  of  gonorrheal  endometritis  is  never  correctly 
made  because  the  salpingitis  which  follows  it  obscures  any 
symptoms  which  might  otherwise  exist. 


TREATMENT  479 

The  diagnosis  of  gonorrheal  salpingitis  is  sufficiently  con- 
sidered under  that  heading,  but  it  should  be  remembered  that 
bilateral  disease  speaks  in  favor  of  a  specific  origin,  that  with  the 
abdomen  open  if  it  is  apparent  that  the  brunt  of  the  process 
has  been  borne  by  the  tubes  rather  than  the  ovaries,  gonorrheal 
infection  is  almost  certain,  and  that  any  mysterious,  acute, 
bilateral  inflammation,  not  accounted  for  by  a  plain  septic 
infection,  is  gonorrheal  on  the  scale  of  chances.  The  value  of 
the  complement- fixation  test  in  the  diagnosis  of  obscure  gonor- 
rhea is  still  uncertain. 

Treatment. — It  is  a  matter  for  regret  that  vaccines  have  so 
limited  a  field  of  usefulness  for  disease  aft'ecting  mucous  sur- 
faces, but  up  to  the  present  this  certainly  is  true. 

The  treatment  of  gonorrhea  is,  therefore,  entirely  a  local 
problem,  and  while  it  cannot  be  cured  its  annoyances  can  be 
mitigated  and  the  disease  itself  be  made  to  assume  the  latent 
form  in  which  it  is  much  less  troublesome.  Gonorrhea  affecting 
the  organs  above  the  internal  uterine  orifice  is  a  surgical  disease 
exclusively,  and  the  most  important  thing  to  be  borne  in  mind 
in  the  treatment  of  gonorrhea  below  this  zone  is  to  do  nothing 
which  might  cause  it  to  extend  higher.  If  the  vulva  alone  is 
involved  the  vulva  only  should  be  treated,  and  in  gonorrhea 
of  the  cervix,  nothing,  neither  sound,  curette,  irrigator,  nor 
medicine,  should  pass  the  internal  uterine  orifice. 

In  hyperacute  cases  of  gonorrhea  rest  in  bed  is  essential. 
As  soon  as  the  acute  symptoms  begin  to  retrogress  the  applica- 
tion to  the  diseased  areas  of  the  most  efficient  gonococcide 
should  be  commenced.  Up  to  the  present  time  silver  nitrate 
solutions  occupy  this  field  almost  to  the  exclusion  of  any  other. 

It  occasionally  happens  that  any  drug  used  persistently 
loses  its  efficacy,  and  when  progress  is  not  apparent  the  vagina 
and  cervix  may  be  swabbed  with  tincture  of  iodin  and  the  or- 
ganic silver  salts  used  in  the  urethra  and  about  the  vulva. 
Occasionally  a  case  is  seen  which  does  better  by  the  use  of 
drying  powders  and  frequently  repeated  light  gauze  packs, 


480  THE    TREATMENT   OF   MENSTRUAL   DISORDERS 

and  the  destruction  of  cervical  glands  by  the  cautery  should  not 
be  overlooked  if  cervical  discharge  is  persistent,  but  on  the  whole 
silver  nitrate  in  varying  strengths  is  our  chief  reliance  in  the 
treatment  of  gonorrhea  limited  to  those  parts  of  the  female  gen- 
italia inferior  to  the  internal  uterine  orifice. 

THE  TREATMENT  OF  MENSTRUAL  DISORDERS 

Under  the  general  subject  of  Symptomatology  the  various 
disorders  of  menstruation  have  been  discussed  and  emphasis 
laid  upon  the  fact  that  all  of  them  are  purely  symptomatic. 
''Remove  the  cause"  is  a  medical  dictum  which  it  is  impossible 
to  obey  at  times,  but  in  the  treatment  of  menstrual  disorders 
every  effort  should  be  made  in  this  direction.  Instances  are 
observed,  however,  in  which  the  etiology  of  the  menstrual 
anomaly  is  not  clear,  or  if  known,  is  not  removable.  Under 
such  circumstances  the  same  attention  must  be  given  to  symp- 
tomatic disturbance  as  would  be  given  to  a  known  disease 
entity. 

Amenorrhea. — In  congenital  absence  of  the  uterus  or  ovaries 
it  is  obvious  that  nothing  can  be  done.  In  genital  atresia  ap- 
propriate treatment  comprises  whatever  operative  measures 
may  be  necessary  to  provide  an  outlet  for  the  retained  secre- 
tions. In  chlorosis,  iron  in  any  form  acts  like  a  specific,  and 
none  of  the  new  preparations  have  any  better  effect  than  the 
old-time  Blaud  pill,  especially  when  given  with  minute  doses  of 
aloes.  Five  to  10  grains  of  freshly  prepared  Blaud's  mass  com- 
bined with  ^ioo  grain  of  aloin,  and  taken  three  times  daily,  pro- 
duces as  satisfactory  results  as  any  of  the  modern  preparations. 
Manganese  binoxid,  potassium  permanganate,  oxalic  acid,  and 
apiol  are  reputed  to  have  some  specific  effect  upon  the  menstrual 
function,  but  cases  are  rare  in  which  such  action  is  necessary 
even  if  possible,  providing  the  primary  disease  is  amenable  to 
treatment.     Prolixity  in  the  use  of  drugs  is   usually  an  evi- 


amenorrhea:  dysmenorrhea  481 

dence  of  paucity  of  ideas  concerning  the  indications  for  their 
employment. 

It  is  possible  that  the  stem  pessary  might  prove  useful  in  a 
patient  whose  ovaries  were  normal  but  whose  uterus  was  in- 
fantile in  size. 

The  most  puzzling  cases  are  those  associated  with  the  sudden 
onset  of  obesity.  In  the  past  we  have  been  entirely  in  the  dark 
concerning  the  etiology  of  the  disorder,  but  recent  investigations 
give  hope  that  the  suspicion  directed  toward  the  internal  secre- 
tions is  correct,  and  that  pathological  processes  in  the  pituitary 
body,  the  thyroid,  and  possibly  the  corpus  luteum,  are  responsi- 
ble for  the  amenorrhea,  which  after  all  may  be  but  one  of  the 
evidences  of  disturbed  metabolism.  Should  this  be  true,  pal- 
liation and  even  cure  will  be  made  possible  in  some  cases  through 
the  use  of  extracts  of  these  organs. 

Dysmenorrhea. — The  treatment  of  dysmenorrhea  may  be 
divided  into  that  for  the  immediate  relief  of  pain,  and  that  for 
the  cure  of  the  condition  upon  which  the  pain  depends.  Nar- 
cotics should  be  avoided  excepting  in  the  severest  cases  and  when 
the  pain  is  absolutely  unbearable,  and  they  should  never  be 
given  more  than  once  or  twice  to  the  same  patient.  It  must  be 
remembered  that  most  patients  .who  have  dysmenorrhea  are 
neurotic,  that  the  pain  recurs  periodically,  and  that  it  may  per- 
sist over  a  protracted  period  in  spite  of  treatment,  all  of  which  is 
peculiarly  favorable  to  the  formation  of  a  narcotic  habit. 

In  the  ordinary  case  general  sedative  measures  without  opi- 
ates give  sufhcient  relief. 

The  hot  sitz  bath  or  full  tub  bath,  continued  until  general 
relaxation  occurs,  is  of  great  value  and  should  be  taken  so  soon 
as  the  pain  begins  and  be  followed  by  rest  in  bed  with  the  appli- 
cation of  a  hot  compress,  the  hot-water  bag,  or  electric  pad,  to 
the  lower  abdomen.  The  bromides  act  well  in  some  cases  if 
given  in  full  doses  for  two  or  three  days  before  the  flow  begins, 
but  their  action  is  too  slow  to  have  any  effect  if  given  after  the 
onset  of  the  pain.  The  coal-tar  products  are  probably  the  best 
31 


482  THE    TREATMENT   OF   MENSTRUAL   DISORDERS 

analgesics  to  use.  Of  these  acetophenitidin  is  the  safest  if  ad- 
ministered in  5-grain  doses,  repeated  every  two  or  three 
hours  until  relief  is  obtained.  Antipyrine  has  a  more  powerful 
anti-spasmodic  effect,  but  the  patient  must  be  watched  for  the 
development  of  untoward  symptoms.  Preparations  of  viburnum 
have  a  wide  vogue  and  have  the  merit  of  being  harmless.  In 
some  instances  they  seem  to  be  of  value,  but  the  proprietary 
preparations  should  be  scanned  carefully  to  see  that  they  do  not 
contain  opium  nor  a  dangerous  quantity  of  alcohol.  The  latter 
drug  acts  very  well  indeed  in  spasmodic  dysmenorrhea,  but  is 
objectionable  for  the  same  reason  that  opium  is. 

Curative  treatment  depends  entirely  upon  the  condition  re- 
sponsible for  the  pain.  Obstruction  should  be  treated  surgically, 
as  should  the  congestive  form  when  due  to  disease  of  the  tubes 
or  ovaries.  Membranous  dysmenorrhea  is  recalcitrant  to  any 
form  of  treatment,  but  sometimes  yields  to  repeated  curettage 
and  dilatation  of  the  cervix. 

The  common  spasmodic  form  is  frequently  made  the  indica- 
tion for  dilatation  and  curettage,  a  procedure  which  occasion- 
ally cures  but  more  frequently  fails  to  accomplish  any  permanent 
good.  Usually  the  pain  is  absent  for  from  one  to  three  periods 
after  dilatation  and  then  recurs  as  severely  as  before,  and  it  is 
not  uncommon  to  have  patients  apply  for  treatment  who  have 
been  dilated  and  curetted  a  number  of  times  without  the  slight- 
est permanent  benefit.  Whatever  the  actual  cause  of  the  pain- 
ful uterine  contractions  may  be,  whether  hyperaesthesia  of  the 
uterine  nerves  increased  by  pelvic  congestion,  pressure  of  the 
opposed  uterine  walls  upon  each  other,  or  swelling  of  the  mucosa 
about  the  internal  uterine  orifice,  in  the  absence  of  actual  disease 
of  the  endometrium  curettage  is  distinctly  not  indicated  unless 
an  unaccountable  sterility  co-exists.  Should  curettage  be  fol- 
lowed by  pregnancy,  permanent  mitigation  of  the  suffering,  but 
not  absolute  cure,  can  be  promised.  But  one  measure  in  the 
author's  hands  has  been  followed  by  success  often  enough  to 
justify  its  routine  adoption,  and  that  is  galvanism  with  one  elec- 


MENORRHAGIA  AND   METRORRHAGIA  483 

trode  in  the  cervix  and  the  other  over  the  abdomen.  Three 
or  four  lo-minute  seances  between  the  periods,  using  10  milli- 
amperes  of  current,  almost  uniformly  gives  relief  for  a  consider- 
able time  and  is  perfectly  safe  providing  the  cervical  electrode 
does  not  pass  through  the  internal  uterine  orifice.  It  is  evi- 
dent that  even  this  method  of  treatment  is  objectionable  in 
virgins,  but  in  a  small  proportion  of  them  some  relief  must  be 
obtained  even  though  it  involves  disagreeable  exposure  and 
embarrassing  methods  of  treatment. 

General  measures  are  always  advisable,  and  are  such  as  serve 
to  keep  the  patient's  general  health  in  the  best  possible  condi- 
tion. Constipation  should  be  overcome,  anaemia  combated, 
and  nerve-racking  work  or  study  modified  or  forbidden  accord- 
ing to  the  severity  of  the  case.  Late  hours  and  dancing  are 
to  be  avoided  immediately  before  the  onset  of  menstruation, 
and  too  close  association  with  the  opposite  sex  must  be  absolutely 
interdicted  if  therapeutic  measures  are  to  be  of  any  avail. 

It  occasionally  happens  in  neurotic  married  women  that 
nothing  gives  relief  and  the  patient  is  made  an  invalid  for  five 
or  six  days  in  every  month.  These  patients  usually  are  perma- 
nently sterile,  and  while  more  or  less  wretched  all  of  the  time  they 
are  so  much  worse  at  the  menstrual  periods  that  operative  meas- 
ures are  necessary  to  put  a  stop  to  the  recurrent  exacerbations 
of  pain.  In  these  cases  removal  of  the  ovaries  has  been  prac- 
tised, but  the  results  are  deplorable  in  that  the  patient's  nervous 
condition  is  made  worse  even  though  the  pain  ceases.  Removal 
of  the  uterus  is  the  correct  procedure  when  menstruation  is  to  be 
permanently  abolished,  since  the  nervous  condition  is  not  ex- 
aggerated by  this  operation  while  the  recurrent  dysmenorrhea 
is  cured.  Fortunately  such  extreme  measures  are  rarely  indi- 
cated, but  in  a  large  number  of  patients  with  menstrual  pain,  one 
is  occasionally  observed  that  cannot  be  reHeved  by  anything 
short  of  the  abolition  of  menstruation. 

Menorrhagia  and  Metrorrhagia. — The  treatment  is  always 
that  of  the  underlying  cause,  but  occasionally  the  bleeding  is  so 


484  THE    TREATMENT   OF   MENSTRUAL   DISORDERS 

alarming  that  measures  for  its  immediate  control  are  necessary. 
Bleeding  from  the  non-puerperal  uterus  can  be  checked  by  snug 
packing  of  the  cervical  canal  and  vagina.  In  mild  cases  very  hot 
prolonged  douches  usually  suffice  and  are  not  so  painful  as  a 
packing  which  is  sufficiently  tight  to  be  of  value. 

If  the  bleeding  point  is  in  the  vaginal  portion  of  the  cervix 
astringents  should  be  added  to  the  water  used  for  douching. 
The  best  of  these  are  tannic  acid,  acetic  acid,  and  acetate  of 
lead,  in  the  proportion  of  i  dram  to  the  pint.  The  power- 
ful haemostatic  effect  of  adrenalin  may  be  utiUzed  when  the 
bleeding  area  is  small  and  suitably  situated  for  local  application, 
but  if  the  hemorrhage  is  from  the  body  of  the  uterus  local  appli- 
cations and  astringent  douches  are  of  no  value.  Ergot  and 
pituitary  extracts  are  useful  in  bleeding  which  is  the  result  of 
myomata  and  congestive  conditions,  such  as  subinvolution,  but 
they  have  little  or  no  effect  in  endometritis  and  malignant  dis- 
ease. Calcium  chloride,  a  dram  daily  in  divided  doses,  taken 
well  diluted,  is  presumed  to  shorten  the  coagulation  time  of  the 
blood  and  so  assist  in  the  control  of  hemorrhage,  and  more 
recently  the  hypodermic  use  of  an  alien  serum,  or  if  this  is  not 
available,  of  diphtheria  antitoxin  (merely  for  the  serum  effect), 
has  been  authoritatively  recommended  and  is  worthy  of  trial  in 
a  desperate  case.  The  danger  of  the  production  of  anaphylaxis 
by  repeated  injection  of  serum  must  not  be  overlooked.  The 
oral  administration  of  styptics  and  astringents  is  useless  and 
should  be  avoided  for  this  reason.  Finally,  every  case  of 
more  than  the  most  moderate  grade  of  severity  should  be  con- 
fined to  bed  until  the  bleeding  is  over,  both  to  modify  the  bleed- 
ing and  conserve  the  general  health. 

REFERENCES 

NORRIS,   C.   C. — Gonorrhea   in   Women,    Its   Pathology,    Symptomatology, 

Diagnosis,  and  Treatment,  etc.     Philadelphia,  1913. 
HCfUNER,  MAX.— Sterility  in  the  Male  and  Female  and  Its  Treatment.     New 

York,  1913. 


REFERENCES  485 

RUNGE. — Beitrag    zur   Aetiologie    und    Therapie   der   weiblichen   Sterilitat. 

Arch.  f.  Gyn.,  1909,  Ixxxvii,  572. 
HtlHNER.— The  Value  of  the  Spermatozoa  Test  in  Sterility.     Urol,  b'  Cut. 

Rev.,  1914,  xviii,  587. 
GRAVES. — Sterility.     Trans.  Am.  Gyn.  Soc,  1913,  xxxviii,  526. 
NEUMANN,  JULIUS.— tJber    Sterilitat.     Wien.  med.  Woch.,  191 1,  Ixi,  1091, 

1158,  1223,  1302,  1366,  1430,  1491. 
SCHAEFFER.— Uber  Haufigkeit,  Ursachen  und  Behandlung  der  Sterilitat  der 

Frauen.     Ein  statisticher  Beitrag.     Zeit.  f.  Bekampf  d.  Geschlechskranheit , 

1913,  XV,  39;  Ahst.  Internal  Ahst.  Surg.,  Aug.,  1914. 
YOUNG  AND   WILLIAMS.— The   Relation   of   Fibroids    to   Sterility.     Bost. 

M.  6°  S.  J.,  191 1,  clxv,  836. 
KOSMAK. — The  Role  of  Ovarian  Disease  in  the  Production  of  Sterility.     Bull. 

Lying-in  Hosp.,  1913,  ix,  107. 
REYNOLDS.— The  Theory  and  Practice  of  the  Treatment  of  Sterility  in  Women. 

/.  A.  M.  A.,  1913,  Ix,  93. 
NORRIS. — Sterility  in  the  Female  without  Marked  Gross  Pathology.     Surg., 

Gyn.  &"  Ohst.,  191 2,  xv,  706. 
WEIL. — Schilddrlisenpraparate   gegen    Sterilitat.     Muen.    med.    Woch.,     191 2, 

Ixix,  2283. 
DAUDE. — Ueber  die  Baderbehandlung  der  weiblichen  Sterilitat.     Med.  Klin., 

1913,  ix,  1209. 
BRICKNER. — Dudley's  Operation  for  Dysmenorrhea  and  Sterility;  A  Review 

•  of  73  Cases.     Am.  J.  Ohst.,  1912,  Ixv,  109. 
McNUTT. — Non-operative  Treatment  of  Sterility,     Med.  Rec,  191 2,  Ixxxi,  1180. 
REYNOLDS.— Prognosis  of  Sterility.     J.  A.M.  A.,  1915,  Ixv,  1151. 
KEHRER. — Chirurgie  der  Sterilitat,     Muen.  med.  Woch.,  191 2,  lix,  2501. 
CARSTENS.— Dysmenorrhea.     N.  York.  M.  J.,  1913,  xiii,  612. 
TAUSSIG. — The  Prevention  and  Treatment  of  Vulvo- vaginitis  in   Children. 

Am.  J.  of  Med.  Set.,  1914,  cxlviii,  481. 
EDITORIAL. — Vaginitis  in  Hospitals,     The  Lancet,  1910,  Ixxxviii,  1354. 
BRUCK,  C. — Die  Vaccinbehandlung  der  Gonorrhoe.     Med.  Klin.,  1914,  x,  47, 
SMITH. — The  Complement  Fixation  Test  in  the  Management  of  Gonococcus 

Vulvo-vaginitis,     A^n.  J.  Diseases  of  Children,  1913,  v,  313. 
HAUSER. — Die   differential-diagnostiche   und   therapeutische   Bedeutung   der 

Gonokkenvaccine  in  der  Gynaekologie.     Arch.  f.  Gyn.,  1913,  c,  305;  Abst. 

Internat.  Ahst.  Surg.,  June,  1914- 
VAN  DE  VELDE. — Spezifiche  Diagnostik  der  weiblichen  Gonorrhoe.     Monats. 

f.  Geh.  und  Gyn.,  191 2,  xxxv,  447. 
HEYMANN  AND  MOOS.— Erfahrungen  liber  Vaccinebehandlung  der  weib- 
lichen Gonorrhoe.     Monats.  f.  Geh.  und  Gyn.,  19 13,  xxxvii,  623. 
FINGER. — Zur    Vakzinationstherapie    des    gonorrhoischen    Prozesses.     Wien. 

med.  Woch.,  1914,  Ixiv,  862. 
PEREZ-GRANDE. — Gonococcie  der  beiden  Geschlechter  und  deren  Behandlung 

mit  polyvalenter  Diplokokkenvakzine.     Zeitsch.  f.  Urol.y  1914,  viii,  795. 


486     STERILITY,    GONORRHEA   AND   MENSTRUAL   DISORDERS 

HAMILTON. — Gonococcus  Vulvo-vaginitis  in  Children.    /.  A.  M.  A.,  1910, 

liv,  1 196. 
HOFMANN. — The  Iodine  Treatment  of  Gonorrhea  in  the  Female.     Interstate 

M.  J.,  1913,  XX,  733. 
HARTZ. — Aqueous  Solutions  of  Iodine  in  the  Treatment  of  Gonorrhea  in  Women. 

Am.  J.  Obst.,  1914,  Ixix,  620. 
CLARK. — Pathology    and    Treatment    of    Gonorrheal    Cervicitis    and    Endo- 
metritis.    Am.  J.  Obst.,  1914,  xix,  961. 
SMITH. — The  Treatment   of   Gonococcus  Vulvo-vaginitis.     Am.   J.   Diseases 

of  Children,  1914,  vii,  230. 
REICH. — Zur  Therapie  der  Amenorrhoe.     Zentralb.f.  Gyn.,  1914,  xxxvii,  1061. 
FRAUMME,  F. — Zur  Behandlung  der  Amenorrhoe.     Zentralb.  f.  Gyn.,  191 2, 

XXX  vi,  1366. 
CARSTENS. — The    Silver    Stem    Pessary    for    Amenorrhea,     Dysmenorrhea, 

Sterility,  etc.     Internal.  J.  Surg.,  191 2,  xxv,  150. 
KOSMINSKI. — Zur  Behandlung  der  Amenorrhoe  mit  Hypophysenenextrakten. 

Deutsche  med.  Woch.,  1914,  xl,  1655;  Abst.  Internal.  Abst.  Surg.,  April,  1915. 
HERMAN. — Dysmenorrhea.     Brit.  M.  J.,  1909,  i,  937. 
REYNOLDS. — Retroversion,    Dysmenorrhea,    and    Sterility.     Stirg.,    Gyn.    & 

Obst.,  1911,  xiii,  17. 
WATKINS. — Infantile  Type  of  Uterus  with  Dysmenorrhea.     Surg.,  Gyn.  & 

Obst.,  1913,  xvii,  461. 
POZZI. — The  Surgical  Treatment  of  the  Most  Frequent  Cause  of  Dysmenorrhea 

and  Sterility  in  Women.     Siirg.,  Gyn.  b'  Obst.,  1909,  ix,  3. 
KLEIN. — Adrenalin   und   Pituitrin  bei  Dysmenorrhoe.     Monals.  f.  Geb.   iind 

Gyn.,  1913,  xxxvii,  169. 
THEILHABER. — Die  Ursachen  und  der  Behandlung  der  essentiellen  Uterus- 

blutungen  und  des  Ausflusses.     Arch.  f.  Gyn.,  1914,  cii,  165. 
KOCH. — Zur  Behandlung  schwerer  Menorrhagien  bei  akutentziindlichen  Ad- 

nexerkrankungen  durch   Portio-injectionen.     Arch.  f.  Gyn.,    191 2,   xcviii, 

297- 
HIRSCH. — Zur  Lehre  von  der  Atiologie  und  Therapie  der  Uterusblutungen. 

Monats.  f.  Geb.  und  Gyn.,  1913,  xxxvii,  420. 
SCHICKELE. — Die    Atiologie    und    kausale    Therapie    der    Uterusblutungen. 

Monats.  f.  Geb.  und  Gyn.,  1914,  xxxix,  290. 
PFAHLER. — Roentgenotherapy  in  Uterine  Hemorrhage.     /.  A.  M.  A.,  1914, 

Ixiii,  628. 
LEVISON,  LOUIS  A.— The  Treatment  of  Hemorrhagic  Conditions  with  Normal 

Human  Blood  Serum.     Interstate  M.  J.,  191 2,  xix,  934. 
BEACH,  C.  T. — Fresh  Animal  Serum  in  the  Treatment  of  Hemorrhage.     Yale 

M.  J.,  1910,  xvii,  8. 
PROBASCO,  E.  B.— Review  of  the  Recent  Work  on  the  Use  of  Normal  Serum 

in  Hemorrhage.     N.  York  State  J.  M.,  191 2,  xii,  32. 


CHAPTER  XVII 
GYNiECOLOGIC  THERAPEUTICS 

There  are  two  ways  of  regarding  a  patient  who  is  the  victim  of 
one  of  the  diseases  which  come  under  the  observation  of  special- 
ists. In  one  the  patient  is  merely  a  case  of  the  disease  presented, 
in  the  other  the  patient  is  an  individual  who  is  the  subject  of  a 
disease.  The  latter  attitude  is  the  correct  one,  since,  for  exam- 
ple, a  patient  with  a  gynaecologic  lesion  or  abnormality  has  not 
only  a  heart,  luiigs,  kidneys,  and  stomach,  but  more  especially 
she  has  glands  of  internal  secretion  and  a  central  nervous  sys- 
tem, and  any  of  these  may  be  diseased  independent  of  her  pelvic 
disorder. 

It  is  a  common  failing  to  overlook  this  fact,  and  to  attempt  to 
cure  the  patient  by  measures  directed  solely  to  the  abnormality 
coming  under  the  specialty  which  happens  to  be  the  one  favored 
by  the  physician  under  whose  observation  she  has  fallen,  and 
this  narrow  attitude  is  responsible,  not  only  for  many  failures  to 
cure,  but  for  much  severe  criticism  as  well.  This  error  perhaps  is 
more  widespread  in  the  practice  of  gynaecology  than  elsewhere, 
since  a  woman  is  only  too  likely  to  consider  her  mysterious 
womb  and  ovaries  as  the  source  of  all  the  ills  to  which  she  is 
heir. 

As  a  matter  of  fact  more  women  suffer  from  the  disease  known 
as  modern  civilization  than  from  diseases  of  their  generative 
organs,  and  even  if  the  latter  are  cured  the  patient  is  in  no  wise 
relieved  of  the  stress  and  strain  imposed  by  her  duties  to  her 
husband  and  children,  her  financial  responsibilities,  and  her 
presumed  social  obligations. 

While  there  are  a  few  drugs,  Hke  ergot  and  pituitary  extract, 
which  have  an  especial  or  specific  action  upon  some  of  the 

487 


488  GYNECOLOGIC   THERAPEUTICS 

female  organs,  there  are  a  number  of  hygienic  and  therapeutic 
measures  which  must  be  utiUzed  if  one  is  to  cure  the  patient 
who  has  a  disease  of  the  genital  organs. 

Some  of  these  measures,  too,  need  to  be  directed  against  con- 
ditions which  are  at  least  quasi-gynaecologic  in  their  origin. 
The  mental  strain  under  which  some  women  labor  as  the  result 
of  fear  of  the  frequent  repetition  of  pregnancy  is"  tremendous, 
and  the  state  of  sexual  erethism  into  which  others  are  thrown 
by  repeated  incomplete  coitus  and  its  effects  upon  their  nervous 
systems  is  deplorable  although  rarely  mentioned. 

The  sterile  woman  is  usually  very  unhappy  also,  and  brooding 
over  her  childless  state  may  do  her  infinitely  more  harm  than 
the  lesion  which  caused  sterility.  Many  things  must  be 
considered  if  one  is  to  cure  his  gynaecologic  patients,  some  of 
which  are  correlated  to  her  pelvic  organs  while  others  really 
bear  no  relation  to  them. 

Under  the  head  of  general  therapeutics  must  be  considered 
such  measures  as  rest,  exercise,  hydrotherapy,  massage,  and 
suggestion. 

Rest. — At  the  present  time  what  most  women  need  is  rest 
from  one  set  of  activities  and  exercise  of  another,  but  some 
conditions  demand  cessation  from  every  sort  of  activity,  both 
physical  and  mental,  and  this  can  be  secured  only  in  a  well- 
regulated  sanatorium.  Such  patients  really  belong  to  the 
nerve  specialists  as  instances  of  functional  neuroses.  However, 
even  neurotic  women  who  have  gynaecologic  abnormalities  and 
disease  should  have  their  gynaecologic  pathology  permanently 
removed,  as  a  source  of  constant  irritation  to  the  nervous  sys- 
tem is  thus  done  away  with,  and  especially  because  the  mind  can 
better  be  put  at  rest  after  the  cure  of  a  local  disorder  than  it 
can  if  a  dreaded  ordeal  remains  to  be  confronted. 

The  great  efficacy  of  change  of  scene  and  of  climate  in  over- 
coming the  nervous  disorders  which  are  associated  with  pelvic 
disease,  is  due  to  the  relief  from  petty  daily  worries  as  well  as 
the  truer  perspective  which  a  patient  obtains  when  removed 


REST  489 

to  a  distance  from  her  problems.  In  functional  disorders  less 
grave  than  actual  neurasthenia  or  major  hysteria  much  good 
is  accomplished  by  a  vacation  period  entirely  away  from  the 
routine  and  humdrum  of  everyday  life.  Some  pelvic  disorders 
of  themselves  demand  absolute  rest  in  bed.  Acute  inflamma- 
tory processes  and  profuse  hemorrhage  require  this  as  the  first 
step  in  their  treatment,  and  recurring  congestion  of  the 
pelvic  organs,  due  to  displacements  of  the  uterus  and  chronic 
inflammatory  disease  of  the  tubes  and  ovaries,  is  best  met  by 
rest  until  the  discomfort  ceases. 

To  tell  a  mechanic's  wife  who  is  attending  to  her  own  house- 
hold duties  and  caring  for  three  or  four  children  that  she  should 
rest  in  bed  is  cruel,  because  for  her  this  is  impossible,  and  only 
too  frequently  her  complaints  of  ill  health  are  regarded  by  the 
family  as  an  evidence  of  laziness.  It  is  in  women  of  this  class 
that  such  wonderful  results  are  obtained  by  minor  operative 
procedures,  not  as  the  consequence  of  operation,  but  because 
the  patient  has  rested  both  physically  and  mentally  and  has 
had  the  novel  experience  of  being  the  recipient  of  every  atten- 
tion instead  of  the  one  who  gave  it. 

Curettage  has  obtained  a  place  of  vast  importance  in  the 
mind  of  the  pseudo-gynaecologist  whose  creed  is,  ''Here's  a 
uterus,  let's  curette  it,"  and  as  his  patient  improves  thereafter 
he  at  once  jumps  to  the  conclusion  that  the  little  instrumental 
meddling  with  the  endometrium  was  responsible.  To  attain  a 
proper  view  of  the  efficacy  of  this  and  many  similar  procedures, 
every  practitioner  of  a  surgical  specialty  should  at  some  time 
have  been  a  general  practitioner.  While  this  might  not  benefit 
his  manual  dexterity  and  operative  ability,  it  would  give  him 
a  broader  view  of  the  indications  for  operation  and  the  results 
which  are  obtained  by  surgical  procedures. 

It  is  not  justifiable  to  frighten  a  patient  with  the  threat  of 
an  operation  whose  beneficial  results  are  largely  attributable 
to  enforced  rest,  catharsis,  etc.,  but  many  women  with  minor 
gynaecologic  disturbances  need  just  such  surroundings  and  sub- 


490  GYNiECOLOGIC   THERAPEUTICS 

sidiary  treatment  as  is  necessitated  by  the  preparation  for 
operation  and  its  after-care.  To  send  such  patients  to  the  hos- 
pital for  two  or  three  weeks  for  observation  or  treatment  is  a  wise 
plan  and  a  justifiable  subterfuge  in  order  that  the  needed  rest 
may  be  obtained,  but  operations  of  any  sort  should  not  be 
performed  unless  definitely  indicated. 

Wholly  aside  from  any  attempt  at  the  rest  cure  or  hospital 
attention,  a  certain  amount  of  daily  rest  is  necessary,  and  this 
varies  somewhat  with  the  individual.  Normally  this  is  taken 
as  sleep,  and  failure  to  secure  that  amount  of  sound  refreshing 
sleep  which  each  individual  needs  soon  sets  the  nerves  on  edge 
and  results  in  the  magnification  of  any  existing  petty  ailment. 

The  habit  of  resorting  to  hypnotic  drugs  as  a  routine  is 
easily  estabhshed,  and  besides  the  injury  done  by  the  drug  itself 
there  is  the  added  damage  of  loss  of  self-control  from  the  con- 
stant dependence  upon  it.  Many  apparently  trivial  measures 
help  to  overcome  sleeplessness,  and  among  the  most  useful  is 
the  habit  of  complete  physical  relaxation  after  retiring.  This  in 
itself  is  restful  and  minimizes  the  discomfort  arising  from  loss 
of  sleep,  while  it  naturally  tends  to  promote  drowsiness.  Ex- 
clusion of  light,  even  to  the  extent  of  wearing  a  bandage  over 
the  eyes,  and  exclusion  of  sound  by  plugging  the  auditory 
meati,  both  serve  to  prevent  external  influences  from  reaching 
the  cerebrum. 

A  warm  bath  before  retiring  promotes  rest  with  some  persons, 
and  a  bath  followed  by  thorough  body  rubbing,  when  massage  is 
not  available,  is  often  followed  by  a  sound  sleep. 

The  avoidance  of  tea  and  coffee  at  dinner  enables  some  nerv- 
ous individuals  to  sleep  without  difficulty,  a  fact  which  they 
learn  for  themselves  without  medical  advice. 

The  occasional  use  of  drugs  to  tide  over  an  acute  crisis  of 
wakefulness  or  anxiety  cannot  be  avoided,  and  those  least  harm- 
ful and  least  likely  to  induce  a  habit  should  be  tried  first. 

A  heavy  dose  of  one  of  the  bromides  at  seven  or  eight  P.M.  on 
two  or  three  successive  nights  will  often  start  the  habit  of  resting 


EXERCISE  491 

and  supplant  a  beginning  habit  of  wakefulness.  This  is  par- 
ticularly true  of  those  who  have  been  ''keyed  up"  to  meet  an 
emergency  and  need  only  to  be  set  right  before  the  habit  of 
lying  awake  becomes  fixed.  Large  doses  of  the  bromides  are 
not  injurious  if  used  for  a  short  time  only,  and  30  grains  of 
sodium  bromide  for  three  or  four  nights  in  succession  can  do 
no  possible  harm.  The  bromides  are  entirely  useless  if  actual 
pain  is  a  factor  in  causing  insomnia. 

The  newer  products,  such  as  trional,  sulphonal,  and  veronal, 
are  usually  safe  so  far  as  their  immediate  effects  are  concerned, 
but  a  habit  is  readily  established  for  any  of  them.  Trional  and 
sulphonal  have  the  further  disadvantage  that  their  soporific 
effect  is  sometimes  delayed  for  many  hours,  so  that  the  patient 
who  takes  them  lies  awake  at  night  and  is  persistently  drowsy 
throughout  the  succeeding  day.  Altogether  they  are  better 
avoided  in  the  class  of  cases  under  consideration,  bearing  in 
mind  that  we  are  dealing  only  with  such  persons  as  are  tem- 
porarily under  gynaecologic  observation,  and  who  are  simul- 
taneously suffering  from  lack  of  rest  and  sleep. 

Exercise. — Those  patients  who  take  the  true  rest  cure  secure 
their  exercise  in  the  form  of  massage  scientifically  given  by  an 
expert,  but  most  gynaecologic  patients  are  improved  by  massage 
and  passive  motion  during  their  stay  in  bed  after  operation,  even 
if  these  are  given  imperfectly.  It  may  seem  ridiculous  to  the 
seamstress  who  uses  a  foot-power  sewing  machine,  or  the  mother 
of  a  family  who  works  the  most  of  her  days,  to  be  advised  that 
she  needs  exercise,  but  such  is  often  the  case.  At  times  it  is  not 
the  muscular  exertion  which  is  needed  so  much  as  the  open  air, 
but  there  can  be  no  objection  to  obtaining  both  ends  simultane- 
ously. Standing  or  sitting  all  day  is  one  of  the  most  trying 
things  possible,  and  many  patients  with  pelvic  pain  from  passively 
congested  veins  in  the  pampiniform  plexus  find  reHef  from  a 
brisk  walk,  precisely  as  do  men  who  have  varicocele. 

Exercise  is  best  taken  as  a  diversion  and  not  as  a  duty.  Thus 
games,  gymnasium  work,  and  even  dancing,  are  often  beneficial. 


492  GYNECOLOGIC   THERAPEUTICS 

Dancing,  however,  is  so  frequently  associated  with  crowded, 
hot,  stuffy  rooms,  and  insufficient  or  improper  clothing,  that  its 
dangers  outweigh  its  benefits.  Active  exercise  in  the  presence 
of  gross  disease  is  almost  always  impossible,  or  at  least  injudi- 
cious, but  the  indefinite,  ill-defined  aches  and  pains  in  the  pelvis, 
which  patients  choose  to  believe  are  organic  in  their  origin,  are 
more  satisfactorily  handled  by  reasonable  hygienic  measures 
than  by  strictly  gynaecologic  treatment. 

Hydro-therapy  and  massage  are  both  valuable  resources  in 
well-equipped  sanatoriums,  but  in  private  gynaecologic  practice 
they  are  rarely  available.  One  minor  hydro-therapeutic  meas- 
ure is,  however,  of  great  value  and  almost  universally  possible, 
that  is,  the  cold  spray  in  the  treatment  of  constipation.  There 
is  no  question  that  the  sudden  appHcation  of  cold  to  the  abdo- 
men quickens  peristalsis.  Advantage  may  be  taken  of  this  by 
the  use  of  a  simple  nozzle  upon  a  rubber  tube  attached  to  the 
cold-water  tap  on  the  ordinary  bath  tub,  the  daily  bath  being 
followed  by  spraying  the  entire  abdominal  wall  with  a  stream 
of  water  applied  with  considerable  force. 

Suggestion. — Suggestion  is  the  most  powerful  auxiliary  force 
in  the  management  of  any  disease  not  necessarily  fatal. 

Suggestion  is  at  the  bottom  of  every  cure  effected  by  Christ- 
ian Science,  sacred  pilgrimages,  and  the  laying  on  of  hands,  and 
in  daily  life  is  the  basic  factor  underlying  the  production  of 
many  apparently  remote  results.  For  example,  the  assurance, 
stated  in  terms  of  positive  conviction,  that  a  patient  would  re- 
cover from  a  given  disease  has  helped  more  than  one  past  a 
crisis  which  otherwise  might  have  been  fatal,  and  the  amount  of 
reserve  nervous  energy  which  may  be  brought  to  bear  in  this 
manner  is  often  surprising.  The  time  for  its  most  successful 
employment  is  when  the  patient  is  under  regular  observation, 
when  the  routine  truthful  encouragement  day  after  day  eventu- 
ally makes  its  influence  felt  even  in  prolonged  chronic  illness. 

While  it  is  in  functional  nervous  disturbances  and  under  the 
care  of  the  trained  neurologist  that  this  method  is  of  special 'use, 


VACCINES,   ETC.  493 

it  can  be  applied  in  a  modified  form  to  meet  the  daily  exigencies 
of  practice  among  women,  but  few  of  whom  are  the  victims  of 
organic  disease  alone.  Fear  of  the  unknown,  and  to  them  the 
unknowable  character  of  their  illness  and  its  outcome,  is  many 
times  productive  of  more  genuine  misery  than  that  caused  by  the 
physical  disease,  and  the  allaying  of  this  fear  becomes  at  once  a 
source  of  comfort  while  it  operates  indirectly  in  securing  com- 
plete recovery. 

An  anaemic  woman  from  whom  a  bleeding  fibroid  has  been 
removed  will  convalesce  more  quickly  if  assured  of  recovery, 
and  her  anaemia  will  improve  more  rapidly  because  her  appetite 
and  digestion  are  better,  and  her  sleep  not  disturbed  by  anxiety 
over  the  outcome.  In  this  way  some  surprising  results  may  be 
secured,  but  an  ovarian  cyst  will  not  cease  to  grow,  a  fibroid 
uterus  to  bleed,  nor  a  carcinoma  to  invade  contiguous  structures, 
no  matter  what  form  of  suggestion  is  used,  although  under  its 
influence  the  patient  may  for  a  time  ignore  all  evidences  of  the 
progress  of  disease.  The  practical  lesson  to  be  drawn  from  these 
facts  is,  that  we  should  remove  or  otherwise  cure  any  tangible 
pathological  conditions  which  are  productive  of  ill  health,  and 
then  assist  recovery  by  appealing  to  the  power  of  suggestion  to 
remove  the  phobias,  fears,  and  dreads,  which  magnify  every 
minor  symptom  into  something  of  major  importance. 

Vaccines,  Antitoxins  and  Specific  Chemical  Therapy. — 
Twenty-five  years  ago,  while  a  medical  student,  the  author  heard 
Victor  C.  Vaughn  make  the  startling  statement  that  the  next 
great  advance  in  medicine  would  be  made  on  the  basis  of  chem- 
ical discoveries.  At  that  time  surgery  was  progressing  so 
rapidly,  not  only  because  of  the  discovery  of  the  bacterial  ori- 
gin of  infections  but  also  by  the  development  of  practical  meth- 
ods of  preventing  them,  that  Vaughan's  prophecy  sounded 
ridiculous. 

In  this  short  time,  however,  there  has  arisen  a  virtually  new 
nomenclature  in  medicine  through  the  activities  of  the  physio- 
logical chemists,  and  the  world  is  undoubtedly  on  the  eve  of 


494  GYNECOLOGIC   THERAPEUTICS 

further  discoveries  which  will  revolutionize  the  management 
of  bacterial  disease.  More  than  this,  the  practical  proof  by 
Ehrlich  that  enormous  quantities  of  poisonous  drugs  may  be 
given  with  impunity,  once  the  chemical  affinity  of  certain  ele- 
ments in  the  drug  for  specific  cells  in  the  body  is  known,  opens 
up  an  almost  incomprehensible  field  for  speculation. 

So  far  as  the  researches  in  immunity,  vaccination,  serum  ther- 
apy, and  specific  chemical  therapy  concern  pure  gynaecology  at 
the  present  moment  there  is  little  to  be  said,  but  the  student 
must  be  fully  abreast  of  the  times  in  his  knowledge  of  these 
subjects  if  he  would  grasp  their  importance  when  the  moment 
arrives  that  they  can  be  applied  to  a  whole  class  of  gynaecologic 
ailments. 

One  may,  perhaps,  say  that  the  use  of  autogenous  vaccines  is 
indicated  in  persistent  mild  infections  about  the  vulva  and 
vagina,  and  that  chronic  draining  intra-abdominal  infections 
may  be  managed  with  safety  in  the  same  manner. 

Stock  vaccines  which  correspond  to  the  bacterial  species  pres- 
ent are  sometimes  successful,  but  the  tendency  to  make  a  rou- 
tine vaccine  prescription  fit  an  individual  case  is  not  likely  to 
prove  satisfactory.  Even  dead  bacteria  carry  a  considerable 
percentage  of  proteid  with  them,  and  the  profound  effect  which 
may  be  produced  by  the  injection  of  minute  quantities  of  for- 
eign proteid,  by  sensitizing  the  body  cells  to  a  later  dose,  has 
been  convincingly  shown  in  the  experimental  production  of 
anaphylaxis. 

The  treatment  of  gonorrheal  infection  by  vaccines  and  sera 
is  still  sub  judice,  and  the  use  of  anti-streptococcic  serum  in 
severe  streptococcus  infection  has  almost  been  abandoned,  save 
in  enormous  doses  and  as  a  last  resort.  What  we  are  dimly 
beginning  to  comprehend  of  the  problems  of  immunity  and  infec- 
tion has  given  a  certain  scientific  basis  to  things  which  were  once 
regarded  as  whimsical  notions,  and  it  is  possible  that  the  old 
fixation  abscess  treatment  for  severe  generalized  infections  may 
again  come  into  vogue. 


CHEMICAL   THERAPY  495 

On  purely  empirical  grounds  two  methods  of  treating  severe 
generalized  infections  have  been  advised  which  after  all  may 
prove  not  to  be  unscientific.  The  beneficial  results  which  seem 
to  have  been  obtained  by  the  intravenous  injection  of  magne- 
sium sulphate  solution  in  obstetric  bacteremia  are  scarcely  open 
to  doubt,  and  the  method  deserves  a  trial  in  all  infections  in 
which  streptococci  can  be  demonstrated  in  the  blood. 

Whoever  may  have  been  the  originator  of  the  idea,  the  sur- 
geons of  the  New  York  Lying-in  Hospital  have  developed  the 
method  most  carefully,  and  it  has  been  found  that  the  solution  is 
best  given  in  i  per  cent,  strength  in  recently  sterilized  distilled 
water.  Of  this  solution  6  to  8  ounces  may  be  given  with  safety 
by  any  accepted  method  of  intravenous  medication,  if  it  is  given 
very  slowly.  How  it  acts  is  unknown,  as  magnesium  sulphate 
per  se  is  practically  devoid  of  antiseptic  power,  but  again,  Ehr- 
h'ch's  chemical  cell-affinity  theory  may  in  time  offer  a  satisfac- 
tory explanation. 

The  other  method,  which  has  been  tried  and  rejected  by  many, 
has  as  its  advocate  the  surgeon  Crede,  and  consists  in  the  intro- 
duction of  colloid  silver  intravenously,  per  rectum,  or  by  inunc- 
tion. The  proprietary  nature  of  the  preparation  and  some 
rather  questionable  advertising  might  well  make  one  hesitate, 
but  on  the  principle  of  '^any  port  in  a  storm"  the  author  has 
used  collargol  intravenously  in  a  number  of  cases  which  to  all 
appearances  were  bound  to  end  fatally.  Some  of  these  re- 
covered, and  because  of  the  belief  that  an  explanation  of  this 
may  sometime  be  found,  either  in  the  specific  character  of  the 
bacteria  responsible  for  the  infection,  or  else  in  the  production 
of  a  chemical  immunity  in  those  body  cells  which  were  proving 
least  resistant  to  the  infection,  he  is  incHned  to  advise  its  use. 

In  a  general  way,  then,  those  grave  infections  without 
marked  local  inflammatory  foci,  in  which  streptococci  are  found 
in  the  blood,  or  even  when  they  are  suspected  only,  should  be 
given  the  benefit  of  possible  help  by  the  intravenous  use  of  one 
of  these  chemicals,  always  bearing  in  mind  that  the  basis  for 


496  GYNECOLOGIC  THERAPEUTICS 

their  use  is  as  yet  empirical,  and  that  the  supposed  results  may 
be  coincidences  only. 

Local  Therapeutics. — The  ^' local  treatment"  of  gynaecologic 
disease  is  tremendously  overdone.  All  that  can  be  accomplished 
in  this  manner  is  the  cure  of  surface  lesions  by  the  production 
of  hyperaemia,  the  direct  application  of  the  cautery,  antiseptics, 
astringents,  deodorants,  etc.,  together  with  a  somewhat  uncer- 
tain influence  upon  deeper  processes  through  the  application  of 
moist  heat  and  hygroscopic  agents  like  glycerin. 

To  these  perhaps  should  be  added  the  effect  of  support  and 
pressure  upon  displaced  and  passively  congested  organs,  and  the 
relief  sometimes  afforded  by  local  blood-letting. 

Local  therapy  further  should  be  confined  to  such  applfcations 
as  can  be  made  to  the  vulva  and  vagina,  intra-uterine  applica- 
tions made  at  the  office  being  far  more  dangerous  than  the  dis- 
eases for  which  they  are  used. 

Liquid  applications  to  the  vulva  should  be  made  by  means  of 
cotton-wrapped  applicators  or  pieces  of  cotton  held  in  for- 
ceps, and  care  should  be  taken  not  to  stain  the  underclothing. 
Drying  powders  can  be  sprinkled  on  the  vulva  by  means  of 
dusting  cans. 

Applications  to  the  vagina  and  vaginal  face  of  the  cervix  can 
be  made  through  the  ordinary  bi-valve  speculum,  through  the 
cyHndrical  glass  speculum,  or  by  placing  the  patient  in  either  the 
Sims's  or  knee-chest  posture  and  retracting  the  perineum. 
Dusting  powders  are  sometimes  used  in  the  vagina,  but  without 
a  powder  blower  some  difficulty  is  met  in  making  their  applica- 
tion uniform. 

Suppositories  are  sometimes  useful  to  convey  medicaments  to 
the  vagina  and  vaginal  face  of  the  cervix,  but  they  are  rather 
mussy.  The  use  of  tampons  of  gauze  or  cotton,  saturated  with 
the  drug  or  solution  which  it  is  desired  to  apply,  is  the  most 
popular  method  of  making  applications  to  the  upper  portion  of 
the  vagina,  while  the  vaginal  douche,  as  a  method  of  promoting 
cleanliness  or  using  astringents  and  antiseptics  as  well  as  apply- 


LOCAL   THERAPY  497 

ing  heat,  is  generally  used  by  the  patient  herself  under  the 
physician's  direction. 

Before  discussing  local  applications  let  it  be  understood  that 
they  should  not  be  used  without  some  definite  idea  as  to  why 
and  what  they  are  expected  to  accomplish,  the  routine  prescrip- 
tion of  a  daily  douche,  with  semi- weekly  visits  to  the  physician's 
office  to  have  a  tampon  apphed  for  "womb  trouble,"  being  not 
only  farcical,  but  unjust  to  the  patient  and  detrimental  to 
scientific  medicine. 

The  galvano-cautery  finds  its  principal  application  in  endo- 
cervicitis  with  erosion  of  the  vaginal  face.  The  small  cautery 
blades  used  by  rhinologists  are  perfectly  adapted  to  this  purpose, 
and  two  or  three  light  stripes  should  be  made  from  well  up  in  the 
cervical  canal,  out  to,  and  extending  across  the  eroded  mucosa. 
This  should  be  repeated  every  ten  days  or  two  weeks  on  another 
portion  of  the  cervix.  The  only  especial  care  that  is  necessary 
is  to  see  that  the  cautery  point  penetrates  well  into  the  mucosa 
but  not  into  the  muscular  tissue.  The  treatment  is  painless  and 
eminently  satisfactory.  Nabothian  follicles  can  be  punctured 
and  destroyed  with  the  same  instrument. 

Local  blood-letting  by  means  of  multiple  punctures  into  the 
vaginal  portion  of  the  cervix,  is  indicated  in  passive  congestion 
as  revealed  by  a  bluish  or  purple  appearance  of  the  cervical 
mucosa.  These  punctures  should  be  made  with  a  sharp  knife,  a 
dozen  or  more  punctures  at  one  sitting,  and  bleeding  is  encour- 
aged by  the  appHcation  of  warm  saline  solution.  Usually  one 
or  two  treatments  suffice  to  temporarily  overcome  the  condition 
and  relieve  the  patient  of  the  profuse  mucous  leucorrhea  which 
is  nothing  but  a  hypersecretion  of  the  cervical  glands.  The 
same  process  of  local  blood-letting  assists  in  reducing  the  size  of 
hypertrophied  lacerated  cervices  containing  large  amounts  of 
cicatricial  tissue.  In  the  days  when  trachelorrhaphy  was  prac- 
tised more  extensively  than  at  present,  this  form  of  depletion,  to- 
gether with  painting  with  iodine  and  the  boro-glycerid  tampon, 
was  used  to  reduce  the  cervix  to  normal  size  before  repair  was 
32 


498  GYNECOLOGIC   THERAPEUTICS 

attempted.  At  present  it  is  felt  that  cervical  amputation  should 
be  done  in  many  cases  in  which  repair  was  formerly  made,  so  that 
preHminary  treatment  is  no  longer  needed,  but  patients  who  are 
in  the  early  child-bearing  period  and  have  cervicitis  from  lacera- 
tion are  much  relieved  by  a  resort  to  this  treatment  from  time  to 
time  until  the  age  of  probable  fecundity  is  past,  after  which  am- 
putation can  be  performed  without  the  probability  of  a  subse- 
quent laceration. 

The  depleting  and  hygroscopic  effect  of  glycerin,  when  appHed 
upon  tampons  to  the  vaginal  vault  and  infra- vaginal  cervix,  has 
been  taken  without  question  and  is  so  universally  accepted  that 
it  probably  is  correct,  although  one  is  unable  to  entirely  dis- 
abuse his  mind  of  a  suspicion  that  the  watery  discharge  which 
results  from  the  use  of  the  glycerin  tampon  consists  of  water 
absorbed  from  the  atmosphere,  rather  than  from  the  patient's 
tissues.  However,  drugs  applied  to  the  vaginal  mucosa  are 
partially  absorbed,  and  no  better  method  of  applying  ichthyol, 
iodine,  etc.,  has  been  devised  than  in  solution  with  glycerin,  but 
it  is  open  to  question  whether  there  is  any  real  effect  upon  the 
pelvic  tissues  from  their  absorption. 

Tampons  have  a  legitimate  use  in  giving  support  to  a  uterus 
which  sags,  and  so  relieving  the  bear-ing-down  feeling  which  a 
partially  prolapsed  uterus  induces.  Such  tampons  soon  become 
matted  and  offensive  when  used  dry  and  without  any  antiseptic 
agent,  and  boric  acid  dissolved  in  the  glycerin  moistening  the 
tampons  enables  them  to  be  retained  longer  than  would  other- 
wise be  possible. 

When  used  for  support  tampons  should  be  applied  with  the 
patient  either  in  the  Sims's  or  knee-chest  posture,  both  of  which 
elevate  the  pelvic  organs.  The  tampons  should  be  soaked  in  the 
glycerin,  squeezed  out,  and  applied  systematically  around  and 
over  the  cervix.  Some  gynaecologists  prefer  to  hll  the  remainder 
of  the  vagina  with  other  tampons  of  non-absorbent  cotton  or 
especially  prepared  wool,  in  order  to  furnish  a  better  column  of 


LOCAL   THERAPY 


499 


support  to  the  structures  above,  but  this  is  essential  in  a  few 
instances  only. 

Temporary  retention  of  a  uterus  which  has  been  replaced 
from  a  retroposition  can  be  accompKshed  by  firm  tamponade  in 
front  of  the  cervix.  In  this  way  one  is  sometimes  enabled  to 
establish  definitely  whether  or  no  the  displacement  is  respons- 
ible for  the  discomfort  of  which  the  patient  complains. 

Tampons  for  office  use  are  made  of  one  long  strip  of  gauze, 
or  of  convenient  sized  pieces  of  absorbent  cotton  tied  to  a  string, 
the  end  of  the  gauze  or  one  end  of  the  string  projecting  at  the 
vulva  for  the  patient's 
convenience  in  removal. 
Ordinarily  they  should 
be  removed  within  48 
hours. 

Tampons  have  a  few 
well-defined  uses,  but 
their  routine  appKcation, 
for  everything  and  anything,  has  led  to  the  derisive  name  of 
''tam^pon  specialist,"  being  applied  to  many  pseudo-gynae- 
cologists. 

Applications  through  the  speculum  are  largely  confined  to  the 
use  of  silver  salts  in  gonorrheal  cervicitis  and  the  vaginitis  which 
is  produced  by  the  cervical  discharge.  Strong  solutions  of 
silver  nitrate  are  applied  to  the  lower  portion  of  the  cervical 
canal  and  the  tip  of  the  cervix  by  means  of  cotton-wound 
appHcators,  and  the  entire  vagina  can  be  bathed  in  weaker 
solutions  which  are  poured  in  through  a  cyHndrical  speculum. 
Before  this  is  done  all  discharge  should  be  wiped  from  the 
vagina.  The  speculum  is  lubricated  with  glycerin  as  oils  and 
vaseline  protect  the  tissues  over  which  they  are  spread.  The 
solution  is  poured  into  the  speculum,  which  is  then  gradually 
withdrawn,  thus  bathing  all  portions  of  the  vaginal  wall  as  it  col- 
lapses beyond  the  end  of  the  instrument.  Solutions  as  strong  as 
10  or  15  per  cent,  can  be  used  for  swabbing,  and  a  2  per  cent,  solu- 


FiG.  233. — Cylindrical  speculum. 


500  GYN.ECOLOGIC   THERAPEUTICS 

tion  may  be  poured  into  the  speculum  if  none  is  allowed  to  come 
in  contact  with  the  vaginal  orifice.  A  strong  saline  solution 
should  be  at  hand  with  which  to  neutralize  the  silver  nitrate  if 
there  is  much  pain  from  its  application,  and  in  any  case  the 
silver  should  be  neutrahzed  and  washed  away  within  a  few  min- 
utes if  it  has  been  used  freely. 

Counterirritation  to  the  vaginal  vault  for  inflammatory 
disease  of  the  tubes  and  ovaries  is  sometimes  practised,  and 
for  this  purpose  tincture  of  iodine  is  most  commonly  used,  fol- 
lowed by  the  appHcation  of  a  glycerin  tampon.  Like  many  of 
our  therapeutic  measures  the  effect  is  open  to  question,  and 
in  any  event  such  treatment  is  not  called  for  during  the  stage  of 
acute  inflammation. 

In  chronic  cases  this  treatment  may  be  practised  at  intervals 
of  three  or  four  days.  It  is  possible  that  the  counterirritation, 
together  with  iodine  absorption,  has  some  effect  in  hastening 
the  resolution  of  inflammatory  exudate  about  an  inflamed  tube 
or  in  the  cellular  tissue  in  the  broad  ligament  bases,  but  no 
positive  evidence  of  this  can  be  adduced,  as  such  masses  undergo 
spontaneous  reduction  in  size  once  the  infection  has  subsided. 
Likewise  the  patient  seems  to  improve  and  her  subjective  symp- 
toms to  disappear  more  rapidly  while  undergoing  treatment,  but 
whether  this  is  from  the  treatment  per  se,  or  the  psychic  effect 
of  expectation  of  cure,  cannot  be  determined.  That  the  latter 
is  an  essential  factor  is  rendered  probable  by  the  fact  that  most 
patients  relapse,  in  the  sense  that  their  subjective  symptoms 
promptly  return,  after  the  conclusion  of  a  series  of  treatments. 

In  favor  of  counterirritation  we  have  the  fact  that  skin 
hypera^sthesia  is  produced  by  inflammatory  conditions  in  the 
abdomen,  and  it  is  quite  possible  that  irritation  of  the  sensory 
nerve  endings  over  such  hypera^sthetic  areas  may  have  a  bene- 
ficial effect  upon  the  intra-abdominal  process.  It  certainly  is 
true  that  a  cantharides  blister,  painting  with  iodine,  or  the 
application  of  a  mustard  plaster  lessens  intra-abdominal  pain, 
but   such    counterirritation  is  most  useful  over  the  anterior 


VAGINAL  DOUCHES  501 

abdominal  wall,  and  its  effect  when  applied  to  a  vaginal  vault 
which  is  not  hyperaesthetic  might  well  be  questioned. 

Vaginal  Douches. — Moist  heat  and  a  variety  of  forms  of 
medication  can  be  appKed  by  means  of  the  vaginal  douche,  but 
the  exact  effect  to  be  obtained  should  be  understood  when  a 
douche  is  ordered,  and  this  can  be  secured  only  if  attention  is 
given  to  a  few  details.  There  is  some  trifling  risk  in  using  the 
vaginal  douche  if  a  nozzle  with  an  opening  at  the  end  is  intro- 
duced too  deeply.  It  would  seem  almost  impossible  for  a 
patient  to  so  place  the  douche  tip  as  to  inject  the  solution  into 
the  uterus,  but  such  accidents  have  happened  repeatedly.  The 
ordinary  result  is  a  severe  attack  of  uterine  colic,  but  it  can 
be  readily  seen  that  serious  infection  might  ensue. 

For  purposes  of  cleanliness  only  the  ordinary  douche  bag  is 
necessary  and  the  position  assumed  by  the  patient  is  unimpor- 
tant, I  per  cent,  warm  salt  solution,  borax  or  boric  acid  in  the 
same  strength  (roughly  a  teaspoonful  to  the  pint)  and  sodium 
bicarbonate  1-2  per  cent.,  all  answer  the  purpose  equally  well. 
The  last  is  somewhat  more  efficacious  than  the  others  for  re- 
moving stringy  mucus,  and  in  sterility  from  hyperacidity  of  the 
vagina  it  sometimes  effects  a  cure. 

The  prevalent  practice  of  using  carbolic  acid  and  mercuric 
chloride  solutions  for  the  cleansing  douche  is  dangerous,  both 
from  the  possibility  of  systemic  poisoning  and  the  certainty  of 
local  irritation  if  the  solution  is  too  strong. 

When  an  antiseptic  effect  really  is  required,  permanganate 
of  potash  solution  in  a  strength  of  i-iooo,  lysol  1-200,  and 
creolin  1-200,  are  all  safer  than  either  carboKc  or  mercuric 
solutions. 

Tannic  acid  and  pulverized  alum  are  astringents  which  are 
often  useful  in  the  declining  stage  of  cervicitis  and  vaginitis. 
These  can  be  ordered  in  the  proportions  of  a  teaspoonful  to  the 
pint,  the  water  used  being  either  as  hot  as  the  patient  can  bear 
(about  ii5°F.)  or  almost  cold. 

Whenever  an  antiseptic  or  astringent  effect  is  needed  it  is 


502  GYNiECOLOGIC   THERAPEUTICS 

desirable  that  the  vagina  should  be  thoroughly  distended  and 
that  the  solution  should  remain  for  some  time  after  its  intro- 
duction. If  this  is  accomplished  large  quantities  are  not  re- 
quired, I  or  2  quarts  being  sufficient.  Distension  can  be  effected 
by  closing  the  vaginal  outlet  around  the  douche  nozzle  and 
allowing  the  fluid  to  escape  from  the  vagina  intermittently, 
and  if  the  douche  is  taken  with  the  patient  in  the  recumbent 
position  in  bed  a  considerable  quantity  of  the  solution  will  be 
retained  in  the  vagina. 

Small  douches  are  inefficient  if  the  effect  desired  is  that  of 
prolonged  moist  heat.  The  prolonged  application  of  hot  fomen- 
tations to  other  portions  of  the  body  appears  to  be  of  use  in 
stimulating  absorption  of  inflammatory  products,  and  doubtless 
a  similar  result  can  be  obtained  in  the  pelvis  by  the  application 
of  moist  heat  through  the  vagina.  For  this  purpose  the  douche 
should  be  as  hot  as  can  be  comfortably  borne,  and  should  be 
continued  for  a  considerable  length  of  time  depending  somewhat 
on  the  subjective  effect  on  the  patient.  Some  women  are  ren- 
dered weak  and  miserable  by  prolonged  frequent  douches,  the 
effect  being  similar  to  that  of  frequently  repeated  hot  baths. 

If  the  patient  is  confined  to  bed  and  in  charge  of  a  nurse  the 
prolonged  douche  is  easily  given  with  the  ordinary  appliances, 
the  douche  can  or  fountain  syringe  being  continually  re-filled. 

If  the  patient  must  care  for  herself,  however,  no  better 
method  can  be  suggested  than  for  her  to  lie  in  a  bath  tub  having 
a  douche  tube  and  nozzle  attached  to  the  mixer  on  the  water 
tap,  a  necessary  precaution  being  that  the  water  shall  be  at  the 
proper  temperature  and  the  degree  of  heat  stationary,  or  a  bad 
burn  may  result.  In  this  manner  the  patient  can  He  in  comfort 
while  the  douche  is  continued  for  a  period  of  from  15  to  30 
minutes  if  no  general  bad  effect  is  produced. 

A  wider  application  of  moist  heat  is  obtained  by  the  sitz  bath, 
in  which  the  patient's  hips  and  pelvis  are  immersed  in  hot 
water  for  from  15  to  20  minutes.  This  is  more  generally  useful 
for  acute  menstrual  suppression  than  for  anything  else,  but  it  is 


RADIO-THERAPY  503 

also  applicable  to  the  relief  of  pain  from  chronic  inflammatory 
pelvic  lesions. 

The  general  effect  of  moisture  and  moderate  warmth  upon 
the  tissues  closely  resembles  that  produced  by  Bier's  hyperaemia, 
and  it  is  possible  that  some  of  the  apparent  good  effects  of 
douching  really  are  produced  by  hyperaemia.  Modifications  of 
Bier's  hyperaemia  method  are  used  upon  the  cervix  by  the  appli- 
cation to  it  of  suction  cups  which  act  in  two  ways;  by  forcibly 
removing  secretions  from  the  cervical  canal,  and  by  inducing 
artificial  passive  congestion  through  which  it  is  presumed  that 
the  resisting  power  of  the  tissues  is  raised. 

In  the  foregoing  discussion  of  local  therapeutic  measures,  it 
is  understood  that  the  methods  described  are  such  as  the  physi- 
cian will  use  in  his  office  or  the  patient  at  her  home,  and  that 
the  conditions  are  such  that  infections  (other  than  gonorrhea 
from  dirty  instruments)  are  not  to  be  apprehended.  Douches 
or  other  applications  after  operative  procedures  are  subject  to 
all  the  risks  incidental  to  post-operative  infection,  and  perfect 
asepsis  is  necessary.  While  cleanliness  of  irrigator  cans,  douche 
bags,  nozzles,  etc.,  should  be  enjoined  upon  the  patient  who  is 
to  use  them,  perfect  sterility  in  the  surgical  sense  is  neither  prac- 
ticable nor  necessary  in  their  household  use. 

The  risk  to  others  from  using  the  same  utensils,  and  the  risk 
to  the  eyes  if  a  gonorrheal  infection  is  present,  should  always  be 
mentioned.  The  author  is  cognizant  of  a  case  of  virulent 
gonorrhea  which  was  conveyed  from  one  woman  to  another 
by  the  neighborly  loan  of  a  douche  bag. 

Radio-therapy. — The  X-rays,  radium,  and  meso-thorium  are 
destined  to  occupy  a  field  in  gynaecology  which  as  yet  is  not 
well  defined.  There  is  no  doubt  that  the  correct  application 
of  the  X-ray  modifies  the  course  of  uterine  fibroids,  and  either 
the  X-ray  or  radiimi  should  be  used  routinely  after  operations 
for  mahgnant  disease  for  their  inhibiting  effect  upon  recurrence. 

Radium  and  meso-thorium  have  a  profound  effect  upon  some 
of  the  varieties  of  malignant  disease  to  which  they  can  be 


504  GYNECOLOGIC   THERAPEUTICS 

directly  applied.  At  present  they  cannot  take  the  place  of 
surgery  in  operable  cancer,  but  in  inoperable  cases  the  occa- 
sional occurrence  of  a  cure  during  their  use  lends  encourage- 
ment to  the  view  that  further  research  and  the  development 
of  exact  methods  will  be  productive  of  a  more  hopeful  attitude 
than  is  now  possible  regarding  the  cure  of  malignant  disease 
without  surgery. 

For  a  knowledge  of  the  technique  most  generally  useful  in 
gynaecologic  disorders,  the  reader  is  referred  to  the  extensive 
reference  table  appended  under  the  subject  which  is  as  yet  too 
young  to  permit  of  dogmatic  statements. 

REFERENCES 

DUBOIS,  PAUL.— The  Psychic  Treatment  of  Nervous  Disorders.  (6th  edi- 
tion), New  York,  1909. 

ALLEN,  RICHARD,  W.— Vaccine  Therapy,  Its  Theory  and  Practice.  (4th 
edition),  Philadelphia,  1913. 

BANDLER,  S.  W. — Medical  Gynaecology.     (3d  edition),  Philadelphia,  1914. 

KELLY,  H.  A.— Medical  Gynaecology.     New  York,  1908. 

FRANK,  R.  T.— The  Clinical  Manifestations  of  Disease  of  the  Glands  of  In- 
ternal Secretion  in  Gynaecological  and  Obstetrical  Patients.  Surg.,  Gyn. 
c^  Obst.,  1914,  xix,  618. 

HILL. — Corpora  Lutea  in  the  Treatment  of  Artificial  Menopause.  Surg.,  Gyn. 
b"  Obst.,  1913,  xvi,  712. 

HILL. — The  Use  of  Corpora.Lutea  in  Gynaecology.  Surg.,  Gyn.  df  Obst.,  19 10, 
xi,  587. 

RtJBSAMEN  UND  KLIGERMANN  — Pharmakologische  Uterusuchungen  an 
der  iiberlebenden  menschlichen  Uterus  und  Tubenmuskulatur.  Zeitsch. 
f.  Gch.  und  Gyn.,  1912,  Ixxii,  272. 

DANNREUT HER  .—Corpus  Luteum  Organotherapy  in  Clinical  Practice. 
J.  A.  M.  A.,  1914,  Ixii,  359. 

LAQUEUR. — Zur  Anwendung  der  physikalischen  Therapie  bei  gynakologischen 
Erkrankungen.     Zeitsch.  f.  Gcb.  und  Gyn.,  1913,  Ixxiv,  211. 

DREUW. — Die  Verwendung  der  Wasserdruck massage  in  der  Gyn.,  etc. 
Deutsche   med.  Woch.,  191 1,  xxxvii,  930. 

RAY.— Some  Special  Applications  of  Spa  Treatment  to  Female  Pelvic  Dis- 
orders.    Practitioner,  191 1,  Ixxxvii,  870. 

WILLIAMS,  CRAGIN,  NEWELL.— Report  on  Vaccine  Therapy  in  Gynaecology 
and  Obstetrics.      Trans.  Am.  Gyn.  Soc,  1910,  xxxv,  181. 

BLUMENTHALL,  F.— Der  gegenwartige  Stand  der  bosartigen  Geschwulste 
(Chemo therapie).     Berl.  klin.  Woch.,  1913,  1,  1942. 


REFERENCES  505 

PINKUSS    UND    KLONINGER.— Zur    Vaccinationstherapie    des    Krebses. 

Berl.  klin.  Woch.,  1913,  1,  1941. 
DAUDE. — Ueber  konservative  und  operative  Behandlung  der   Frauenkrank- 

heiten  im  Bade.     Med.  Klin.,  191 2,  viii,  1112. 
MUMFORD,  J.  G. — Psychical  End  Results  Following  Major  Surgical  Opera- 
tions.    Publications  of  Mass.  Gen.  Hosp.,  1909,  ii,  465. 
KLEIN. — Die  Bedeutung  der  Hydrotherapie  fiir  den  Gynaekologen.     Zeit.  f. 

physikal  und  didtet   Therap.,   1914,  xviii,   17;  Absf.  Internal.  Abst.  Surg., 

August,  1914. 
VAUGHAN. — Cancer  Vaccine  and  Anticancer  Globulin,  etc.     /.  A.  M.  A., 

1914,  Ixiii,  1258. 
KREUSCHER,  P.  H. — Some  Observations  on  Vaccine  and  Serum  Therapy 

from  Dr.  Murphy's  Clinic.     III.  M.  J.,  1913,  xxiv,  331. 
GREEN  AND  KONRAD.— The  Treatment  of  Uterine  Carcinoma  with  Cancerous 

Ascitic  Fluid.     Bost.  M.  is^  S.  J.,  1914,  clxx,  352. 
DEAVER,  DACOSTA,  AND  PFEIFFER.— Vaccine  Therapy  as  an^Adjunct  to 

Surgery.     Surg.,  Gyn.  &'  Obst.,  1910,  xi,  138. 
HARRAR. — The  Treatment  of  Puerperal  Strep tococcemia  with  Intravenous 

Injections  of  Magnesium  Sulphate.     Am.  J.  Obst.,  1913,  Ixviii,  825. 
ILL,  E.  J. — Intermittent  Pressure  in  Pelvic  Inflammatory  Disease.     Trans. 

Am.  Assn.  Obst.  &°Gyn.,  1913,  xxvi,  98. 
KOCH,  J.  A. — The  Dry  Treatment  of  Leucorrhea  and  Cervical  Erosions.     III. 

Med.  J.,  1913,  xxiv,  330. 
KRONIG. — ^The  Roentgen  Rays,  Radium,  and  Mesothorium  in  the  Treatment 

of  Uterine  Fibroids  and  Malignant  Tumors.     Am.  J.  Obst.,  1914,  Ixix,  205. 
ADLER,     L. — tJber     Radiumbehandlung     bei     Gebarmutterkrebs.       (Klinik 

Schauta.)     Monats.f.  Geb.  und  Gyn.,  1915,  xli,  145. 
STERN. — X-ray  Treatment  of  Uterine  Fibroids,  Menorrhagia,  and  Metror- 
rhagia.    Am.  J.  Obst.,  1913,  Ixvii,  1133. 
HEIMANN. — Die    Gynakologische    Rontgentherapie.     Monats.   f.    Geb.    und 

Gyn.,  1913,  xxxvii,  325. 
D(3dERLEIN. — Rontgenstrahlen   und   Mesothorium   in   der   gynakologischen 

Therapie.     Monats.  f.  Geb.  und  Gyn.,  1913,  xxxvii,  553. 
PINKUSS. — Die  Mesothoriumbehandlung  bei  haemorrhagischen  Metropathien 

und  Myomen.     Deutsche  med.  Woch.,  1913,  xxxix,  1041. 
PFAHLER. — Roentgenotheraphy  in  Gynaecology.     Tr.  Am.  Rontg.  Ray  Soc, 

1913- 
ABBE. — Uterine     Fibroids,    Menorrhagia,    and     Radium.     Med.    Rec.    191 5, 

Ixxxvii,  379. 
HIRSCH. — Die  Rontgenbehandlung  bei  Myomen  und  Fibrosis  uteri.     Fort- 

schritte  auf  dem  Gebiete  der  Rontgenstrahlen,  1913,  xx,  373. 
WERTHEIM. — Radiumbehandlung     des     Gebarmutterkrebses.     Wien.    klm. 

Woch.,  1913,  xxvi,  1648. 
KRONIG  UND  GAUSS.— Die  Strahlentherapie  in  der  Gynakologie.     Roentgen 

oder  Radiumtherapie?     Zentralb.  f.  Gyn.,  1913,  xxxvi,  153. 


5o6  GYNECOLOGIC   THERAPEUTICS 

BORDIER  AND  COLLEAGUES.— Symposium  on  Roentgentherapy  in  Gynaeco- 
logy.    Forts,  a.d.  Geb.  d.  Roentgenstrahlen,  1913,  xx,  1-33. 

MOHR. — Statische  Bearbeitung  der  bis  zum  i  Januar  1913  Verofifentlichen  mit 
Rontgenstrahlen  behandelten  gynakologischen  Erkrankungen.  Forts,  a.d. 
Geb.  A  Roentgenstrahlen,  19 13,  xx,  105. 

SPARMANN. — Experiences  in  the  Treatment  of  Malignant  Tumors  by  Radium. 
Annals  of  Surg.,  1914,  Ix,  567, 

KELLY  AND  BURNAM.— Radium  in  the  Treatment  of  Uterine  Hemorrhage 
and  Fibroid  Tumors.     /.  A.  M.  A.,  1914,  Ixiii,  622. 


CHAPTER  XVIII 

DISEASES   CLOSELY  RELATED   TO   OR  ASSOCIATED 
WITH  GYNiECOLOGIC  LESIONS 

Urethritis.^ — Acute  urethritis  in  women,  as  in  men,  is  generally 
of  gonorrheal  origin.  In  the  acute  stage  the  chief  complaints 
are  burning  and  smarting  with  frequent  urination.  On  exami- 
nation the  urethra  may  be  somewhat  reddened,  but  the  pathog- 
nomonic evidence  is  presented  by  the  discharge  of  pus  from  the 
meatus  on  stripping  the  urethra.  In  the  female  urethra  there 
is  no  powerful  cut-off  muscle  to  prevent  the  external  appear- 
ance of  the  discharge  when  only  the  vesical  end  of  the  urethra 
is  involved. 

Care  is  needed  in  order  to  distinguish  a  discharge  from  the 
urethra  proper  from  one  having  its  origin  in  the  para-urethral 
ducts. 

Treatment. — Urethritis  in  the  female  is  more  amenable  to 
treatment  than  in  the  male  by  reason  of  the  shortness  of  the 
urethra  and  the  simpHcity  of  its  anatomical  relationships.  In 
the  acute  stage  free  dilution  of  the  urine  by  the  ingestion  of 
large  quantities  of  water,  and  the  avoidance  of  alcohol  and  meat 
leads  to  prompt  ameHoration  of  the  S3niiptoms,  while  prolonged 
hot  douches  and  hot  sitz  baths  overcome  the  tenesmus.  As 
the  symptoms  abate  local  applications  of  the  silver  salts  should 
be  made  to  the  urethra,  but  unless  cystitis  is  a  compHcation 
these  applications  should  not  be  made  by  injection  lest  the 
infection  be  carried  into  the  bladder.  A  short  small  urethro- 
scope is  introduced,  and  through  this  is  passed  a  cotton- wrapped 
applicator  saturated  with  the  solution  which  it  is  desired  to  use. 
In  the  more  active  stage  a  weak  solution  of  protargol  or  a  strong 
solution  of  argyrol  may  be  applied  every  day  or  two,  but  as 

507 


5o8      DISEASES    ASSOCIATED    WITH    GYNiECOLOGIC   LESIONS 

the  inflammation  subsides  these  can  be  changed  for  sl  }^  to  i 
per  cent,  solution  of  silver  nitrate. 

If  the  para-urethral  ducts  are  involved  they  should  be  split 
to  their  ends  with  a  small  knife  and  then  touched  with  a  strong 
silver  solution  or  the  solid  stick. 

Acute  Cystitis. — Cystitis  in  women  could  be  made  the  subject 
of  a  monograph,  but  only  enough  will  be  given  here  to  point 
out  some  of  the  pitfalls  in  diagnosis  and  outline  the  treatment 
of  the  ordinary  forms. 

While  it  is  conceivable  that  acute  cystitis  might  be  caused  by 
descending  infection  from  the  kidney  and  ureter,  or  that  it 
might  be  produced,  as  are  some  kidney  infections,  through  the 
medium  of  the  blood  stream,  it  is  a  fact  that  practically  all  the 
cases  which  one  sees  are  the  result  of  an  infection  which  ascends 
through  the  urethra  or  is  introduced  into  the  bladder  by  means 
of  instruments.  The  organisms  most  frequently  responsible 
for  acute  cystitis  are  the  colon  bacillus  and  gonococcus,  and 
while  other  pus-producing  micro-organisms  are  sometimes  found, 
the  urinary  report,  "motile  bacilli  resembling  colon  bacilli," 
is  so  common  as  to  be  monotonous.  Gonorrheal  cystitis  is  not 
so  frequently  encountered  as  in  the  male,  probably  because 
drainage  is  better  than  from  the  male  urethra,  and  also  because 
instruments  and  irrigations  are  not  so  frequently  resorted  to  in 
the  treatment  of  urethritis  in  the  female.  The  factors  of  dis- 
turbed blood  and  nerve  supply,  such  as  follow  hysterectomy, 
direct  injury  by  catheters,  over-distension  and  exposure,  can- 
not be  disputed,  and  they  probably  act  by  lowering  the  resistance 
to  infection,  the  latter  being  easily  supplied  in  the  case  of  the 
colon  bacillus  by  its  constant  presence  about  the  anus  and 
perineum. 

The  immediate  result  of  acute  infection  of  the  bladder  is  an 
engorgement  of  the  mucous  membrane  with  blood,  desquama- 
tion of  the  superficial  layer  of  cells,  and  pus  formation,  just  as 
in  acute  infection  of  mucous  membranes  elsewhere.  Desquama- 
tion may  be  so  extensive  as  to  lead  to  superficial  ulceration 


ACUTE   CYSTITIS  509 

• 

and  bleeding,  the  process  usually  being  most  severe  about  the 
base  of  the  bladder. 

Symptoms  and  Diagnosis. — The  subjective  symptoms  of 
cystitis  are  few  in  number  but  striking  in  their  intensity.  Fre- 
quent painful  urination  and  tenesmus,  with  aching  about  the 
vulva  and  low  in  the  back,  call  attention  to  the  bladder  at 
once,  the  severity  of  the  symptoms  being  dependent  both  upon 
the  virulence  of  the  infection  and  the  portion  of  the  bladder 
involved. 

There  may  or  may  not  be  elevation  of  temperature  and  pulse, 
but  a  little  increase  in  both  is  usual. 

In  acute  cystitis  the  bladder  is  acutely  sensitive  to  any  sort 
of  examination  and  cystoscopy  is  rarely  called  for,  but  if  prac- 
tised, flakes  of  muco-pus  will  be  observed  adhering  to  the  en- 
gorged, reddened,  bladder  wall. 

The  urine  in  acute  cystitis  may  be  acid,  alkaline,  or  neutral 
(unless  there  is  retention  it  is  not  likely  to  be  ammoniacal),  and 
it  is  cloudy  from  suspended  epithelium,  pus,  blood,  and  bacteria. 
On  chemical  examination  there  is  always  some  albumen,  the 
quantity  being  directly  proportionate  to  the  pus  and  blood 
present.  It  should  perhaps  be  emphasized  that  filtering  the 
urine  to  remove  pus  and  blood  does  not  remove  the  albumen 
as  the  latter  is  derived  principally  from  the  serum  rather  than 
the  formed  constituents  which  are  removed  by  filtration. 

Microscopically  large  patches  of  epithehal  cells  may  be  found, 
which  are  of  the  characteristic  bladder  type.  If  the  case  be 
very  severe  the  smaller  underlying  cells  of  the  bladder  mucosa 
are  present  and  may  be  mistaken  for  renal  epithelium.  Pus 
corpuscles  are  always  present  and  blood  cells  are  usually  found, 
while  the  causative  micro-organisms  are  observed  in  the  cen- 
trifugalized  specimen. 

The  diagnosis  is  easy  if  a  careful  history  is  taken  and  an 
examination  made,  cystitis  itself  being  rarely  overlooked,  the 
real  danger  being  that  serious  renal  lesions  may  be  thought 
to  be  vesical  only.     A  patient  with  a  history  of  gonorrhea  or 


5IO      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC   LESIONS 

• 

of  repeated  catheterizations,  especially  after  hysterectomy, 
who  has  frequent,  painful  urination  and  passes  purulent  urine, 
rarely  has  anything  but  acute  cystitis  if  the  onset  was  sudden 
and  the  symptoms  of  short  duration. 

Aching  in  the  loins  and  sharp  elevation  of  temperature  com- 
ing on  several  days  after  the  onset  of  the  bladder  symptoms 
may  mean  pyeHtis,  and  probably  do  if  the  pain  appears 
first  on  one  side  and  a  little  later  on  the  other.  Involve- 
ment of  the  pelvis  of  the  kidney  may  suffice  to  produce  a  few 
casts  and  more  albumen  than  can  be  accounted  for  by  the  pus 
and  blood  alone,  and  involvement  of  the  parenchyma  of  the 
kidney  always  causes  a  ''shower"  of  casts  and  far  more  albumen 
than  either  cystitis  or  pyeHtis. 

Calculous  renal  colic  causes  sudden  tenesmus  and  traces  of 
blood  and  pus  in  the  urine,  but  the  intense  pain  of  calculous 
coHc,  the  disproportionately  small  amount  of  pus  and  greater 
number  of  blood  cells,  the  absence  of  masses  of  bladder  epithe- 
lium, and  the  absence  of  bacteria  during  the  first  attack,  usually 
suffice  to  distinguish  them,  and  if  any  doubt  remains  it  may  be 
dispelled  by  a  radiogram.  Acute  haematogenous  infection  of 
the  kidney  has  few  points  in  common  with  cystitis,  and  a  patient 
with  the  former  presents  a  desperately  ill  appearance  at  once. 
Over-distension  of  the  bladder,  with  pain,  frequency,  and  drib- 
bhng,  cannot  be  mistaken  for  cystitis  if  the  patient  is  properly 
examined. 

The  course  of  acute  cystitis  is  toward  rapid  spontaneous 
recovery  although  slight  bladder  irritability  may  remain  for 
some  time,  but  the  possible  extension  of  the  infection  upward 
to  the  kidney  makes  the  disease  more  serious  than  is  generally 
appreciated. 

Treatment. — The  treatment  of  acute  cystitis  is  first  of  all, 
rest,  the  patient  herself  often  volunteering  the  information 
that  she  is  better  at  night.  During  the  stage  of  acute  inflam- 
mation medical  treatment  should  be  directed  toward  rendering 
the  urine  bland  and  keeping  the  bladder  itself  at  rest.     Con- 


ACUTE   CYSTITIS  51I 

centrated  urine  is  irritating,  and  for  this  reason  the  ingestion 
of  large  quantities  of  water  and  the  use  of  the  alkahne  diuretics 
are  indicated.  Alcohol  should  be  forbidden  and  the  diet  limited 
to  milk,  which  promotes  diuresis  while  it  does  not  increase  uri- 
nary acidity.  The  frequency  of  urination  may  be  lessened  by 
the  use  of  bromides  and  belladonna,  but  opiates  are  needed 
if  the  pain  is  excessive.  It  is  probable  that  urinary  antisepsis 
is  assisted  by  the  use  of  hexamethylenamine  although  in 
very  large  doses  this  itself  causes  strangury.  In  any  event 
it  should  be  given  with  large  quantities  of  water  to  prevent  irri- 
tation of  the  stomach,  and  10  grains  may  be  given  four  times  a 
day  with  safety.  Methylene  blue  is  reputed  to  be  of  value  for 
the  same  purpose,  but  the  staining  of  the  patient's  linen  is  so 
pronounced  that  it  is  somewhat  of  a  nuisance.  Hot  sitz  baths, 
hot  douches,  and  moist  heat  appHed  above  the  pubes,  all  relieve 
pain  and  promote  comfort,  and  thus  hasten  recovery. 

Local  treatment  is  not  indicated  during  the  stage  of  acute 
inflammation.  Such  treatment  at  this  time  is  extremely  pain- 
ful, and  installations,  bladder  irrigation,  etc.,  are  best  reserved 
for  the  declining  stage  unless  there  is  a  great  quantity  of  pus  in 
the  urine.  An  exception  to  the  rule  of  no  interference  during 
the  acute  stage  is  to  be  made  in  patients  who  must  for  any  reason 
be  catheterized,  when  gentle  irrigation  after  the  bladder  is 
emptied  by  the  catheter  seems  to  be  of  benefit.  As  the  acute 
symptoms  subside,  cautious  and  gentle  irrigation  with  a  warm 
saturated  solution  of  boric  acid  or  a  i  per  cent.  saHne  solution 
may  be  tried,  and  if  found  not  to  cause  pain  it  should  be 
repeated  once  or  twice  a  day. 

If  boric  solution  is  used  for  the  irrigation  one  of  the  organic 
silver  preparations  may  be  thrown  into  the  bladder  after  the 
boric  solution  is  evacuated.  Two  or  3  drams  of  10  to  20 
per  cent,  solution  of  argyrol,  left  in  the  bladder  in  this  manner, 
acts  with  apparent  benefit. 

Great  protraction  of  the  symptoms  and  the  continued  pres- 
ence of  pus  in  the  urine  calls  for  the  use  of  the  cystoscope  in 


512      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC   LESIONS 

order  to  differentiate  between  persistent  cystitis  and  lesions 
higher  in  the  urinary  tract.  If  areas  of  extreme  redness  or 
superficial  ulceration  are  found  in  the  bladder  they  should  be 
touched  with  solutions  of  nitrate  of  silver  applied  to  the  in- 
flamed patch  only.  The  Kelly  cystoscope  should  be  utihzed  for 
this  purpose  as  the  application  can  be  made  by  the  direct  aid 
of  sight  and  with  no  risk  of  dropping  the  solution  into  the  blad- 
der. Even  when  done  with  the  greatest  care  this  procedure 
causes  some  pain,  and  the  careless  dropping  of  nitrate  of  silver 
solution  into  the  bladder  is  so  painful  that  it  is  likely  to  induce 
the  patient  to  discontinue  treatment. 

Chronic  Cystitis. — Chronic  cystitis  as  a  primary  disease  in 
women  is  not  very  common,  most  cases  so  diagnosed  being 
recurrent  acute  cystitis,  ureteritis,  pyelitis,  tuberculosis  of  the 
kidney  and  ureter  as  well  as  the  bladder,  benign  or  malignant 
growths  in  the  bladder,  or  irritable  bladder  from  the  pressure 
of  tumors  or  the  dragging  of  adhesions.  Interference  with  the 
blood  and  nerve  supply  of  the  bladder  during  the  performance 
of  hysterectomy  seems  to  predispose  to  infection,  and  this 
infection  may  become  chronic  because  of  lowered  resistance 
from  the  same  source.  The  presence  of  a  calculus  or  other 
foreign  body  in  the  bladder  leads  sooner  or  later  to  chronic 
cystitis,  as  does  a  vesico-vaginal  fistula  or  an  abscess  which  has 
opened  into  the  bladder  from  the  surrounding  structures. 
There  is  a  form  of  true  chronic  cystitis  in  which  the  bladder  wall 
becomes  thickened  from  inflammatory  infiltration,  the  cavity 
of  the  viscus  becoming  progressively  smaller  as  the  inflam- 
matory process  progresses,  but  many  of  the  symptoms  which 
formerly  were  presumed  to  be  due  to  chronic  cystitis  have  been 
relegated  to  the  same  category  by  the  urologist  as  have  the 
symptoms  of  indigestion  by  the  abdominal  surgeon.  The  symp- 
toms are  present,  but  the  lesion  usually  is  elsewhere.  One 
marked  exception  to  this  rule  is  the  chronic  cystitis  which  some- 
times results  from  the  decomposition  of  urine  retained  in  the 
bladder  of  a  patient  who  has  an  old  cystocele.     Even  here  it  is 


CHRONIC   CYSTITIS  513 

true  that  the  cystitis  is  not  primary,  but  it  may  need  treatment 
after  the  causative  lesion  is  removed. 

The  symptoms  of  chronic  cystitis  are  pain,  frequent  urination 
and  tenesmus,  and  the  passage  of  small  quantities  of  purulent, 
sometimes  blood-stained,  urine.  Examination  of  the  urine 
shows  it  to  be  cloudy,  either  acid  or  alkah'ne  (always  the  latter 
if  chronic  retention  is  present),  and  microscopically  the  centrifu- 
galized  sediment  shows  pus  cells,  bladder  epithehum,  and 
sometimes  blood.  The  infecting  micro-organism,  if  other  than 
the  tubercle  bacillus,  is  readily  found. 

The  cystoscope  should  always  be  used  in  examining  patients 
who  present  the  cardinal  symptoms  of  chronic  cystitis  unless 
the  etiology  is  plain.  By  its  use  the  inflamed  portion  of  the 
mucous  membrane  can  be  seen,  as  well  as  ulcers,  foreign  bodies, 
and  new  growths. 

Differential  Diagnosis.- — The  process  of  dift'erentiating  chronic 
cystitis  from  other  lesions  which  present  the  same  subjective 
symptoms  consists  first,  in  ascertaining  the  actual  condition 
of  the  bladder  by  inspection,  and  second,  in  ehminating  the 
graver  lesions  higher  in  the  urinary  tract.  Ulcerated  areas, 
elsewhere  than  about  the  ureteral  orifices,  point  to  an  uncompli- 
cated bladder  lesion,  but  an  erosion  which  is  confined  to  one 
ureteral  orifice  at  once  leads  to  suspicion  of  disease  of  the  cor- 
responding kidney.  If  coincidently  the  urine  is  acid  and  the 
quantity  of  pus  small,  while  urination  is  frequent  and  the 
amount  passed  in  24  hours  is  above  normal,  the  probabihty  of 
tuberculosis  of  the  kidney  is  so  great  that  repeated  search  for 
the  tubercle  bacillus  must  be  made.  Failure  to  find  the  bacillus 
does  not  mean  that  one  is  on  the  wrong  track  until,  or  unless, 
animal  inoculation  also  proves  negative. 

Pus  or  blood  coming  from  one  or  both  ureters  stamps  the 
case  at  once  as  something  more  serious  than  cystitis. 

Painful  frequent  urination,  without  pus,  blood,  or  micro- 
organisms, is  a  common  complaint  and  means  that  there  is  no 
bladder  infection,  but  foci  of  infection  in  the  kidney  may  drain 

33 


514      DISEASES    ASSOCIATED    WITH    GYNECOLOGIC   LESIONS 

intermittently  and  at  the  same  time  cause  persistent  bladder 
irritation,  so  that  repeated  negative  findings  are  necessary 
to  rule  out  a  kidney  lesion.  Once  this  is  accomplished  the 
bladder  symptoms  may  be  classed  as  neurotic  if  there  is  no 
abnormal  pressure  upon  the  bladder  or  ureter. 

Treatment. — The  causative  lesion  must  be  given  attention  in 
every  case  of  chronic  cystitis.  Cystocele  should  be  corrected, 
abnormal  openings  into  the  bladder  closed,  and  foreign  bodies 
removed,  before  the  bladder  itself  can  be  treated  successfully. 

Tuberculosis  and  abscess  of  the  kidney  should  have 
surgical  attention,  after  which  the  bladder  tends  to  recover 
spontaneously. 

For  the  cystitis  itself  both  internal  medication  and  local 
treatment  are  useful. 

Hexamethylenamine  internally  up  to  30  or  40  grains  daily, 
if  the  urine  is  acid,  probably  has  an  inhibitory  effect  on  the 
growth  of  micro-organisms  in  the  urinary  tract.  If  the  urine 
is  persistently  ammoniacal,  sodium  or  ammonium  benzoate  in 
doses  of  10  grains  three  times  daily  is  of  service,  as  it  is  excreted 
as  hippuric  acid  and  thus  helps  to  overcome  the  alkalinity  of  the 
urine. 

As  in  acute  cystitis,  the  greater  the  dilution  of  the  urine  the 
less  irritating  it  is,  and  large  quantities  of  water  should  be  taken 
daily. 

Also  as  in  acute  cystitis,  the  use  of  mild  sedatives,  such  as 
belladonna  and  the  bromides,  overcomes  the  hypersensitiveness 
of  the  bladder  and  internal  orifice  of  the  urethra  and  lessens  the 
frequency  of  urination,  and  in  this  manner  indirectly  assists  in 
bringing  about  a  cure  by  securing  rest  for  the  bladder  wall. 

The  importance  of  the  patient's  general  condition  should  not 
be  overlooked  when  combating  a  chronic  infection,  and  every- 
thing possible  should  be  done  to  bring  this  up  to  the  highest 
possible  point.  Vaccine  treatment  has  been  discussed  in  the 
section  on  gyna^'cologic  therapeutics.  It  is  still  somewhat  uncer- 
tain but  should  be  tried  if  the  infection  is  persistent. 


HEMORRHOIDS  5 1 5 

It  is  upon  local  treatment,  however,  that  the  greatest  depen- 
dence must  be  placed.  Here  bladder  irrigations  with  the  milder 
antiseptics,  such  as  saturated  boric  acid  solution,  are  of  value, 
and  the  instillation  of  silver  salts  is  indicated  after  the  bladder 
is  empty.  Argyrol,  even  in  solutions  up  to  15  or  20  per  cent., 
is  not  irritating  and  should  be  used  once  or  twice  daily. 

In  obstinate  cases  direct  applications  of  silver  nitrate  should 
be  made  to  the  bladder  wall,  using  a  2  per  cent,  solution  through 
the  endoscope.  This  should  be  applied  only  to  ulcers  or  deeply 
congested  small  areas  and  may  be  repeated  once  or  twice  a  week. 

Emulsions  of  orthoform  are  anaesthetic  and  reheve  the  pain, 
but  they  cannot  be  efhciently  sterihzed  and  their  use  adds  the 
risk  of  a  mixed  infection. 

Iodoform  in  sterilized  olive  oil  may  be  injected  once  daily 
if  tuberculous  cystitis  is  present. 

An  ingenious  method  of  applying  medicaments  upon  the  out- 
side of  rubber  balloons,  which  are  inflated  after  their  insertion 
into  the  bladder,  has  been  devised  at  the  Johns  Hopkins  Hos- 
pital. This  is  especially  useful  in  cases  of  true  chronic  cystitis 
with  marked  contraction  of  the  bladder  wall,  but  the  treatment 
is  too  complicated  for  office  use.  If  the  case  fails  to  respond  to 
ordinary  methods  after  prolonged  treatment,  temporary  drain- 
age through  an  opening  in  the  vesico-vaginal  septum  is  indi- 
cated as  a  last  resort.  The  risk  of  mixed  infection  is  not  great 
because  the  bladder  is  always  empty,  neither  does  such  an 
opening  often  eventuate  in  a  permanent  fistula,  but  either  of 
these  disagreeable  sequels  might  happen  and  the  possible  con- 
sequences should  be  considered  before  drainage  is  instituted. 

HEMORRHOIDS 

One  of  the  very  common  comphcations  of  gynaecologic  disease 
is  a  more  or  less  varicose  condition  of  the  hemorrhoidal  veins 
which  persists  in  a  large  percentage  of  women  who  have  borne 
children. 


5l6      DISEASES    ASSOCIATED    WITH   GYNECOLOGIC    LESIONS 

Hemorrhoids  are  classified  as  external,  internal,  or  mixed, 
according  to  whether  they  are  situated  in  and  beneath  the  skin 
surrounding  the  anus,  above  the  white  line  joining  the  skin  and 
mucous  membrane,  or  whether  they  are  a  combination  of  both. 

External  hemorrhoids  are  either  quiescent  tabs  of  skin  about 
the  anus  or  thrombotic  varicosities.  The  former  are  of  little 
consequence  although  they  may  become  inflamed  and  give  rise 
to  considerable  annoyance. 

The  thrombotic  external  hemorrhoid,  on  the  contrary,  is  one 
of  the  most  exquisitiely  painful  minor  disorders  imaginable,  as 
the  thrombotic  process  frequently  extends  upward  so  that  the 
inflamed  vein  is  caught  in  the  grasp  of  the  sphincter.  Defeca- 
tion, urination,  every  attempt  to  control  expulsion  of  flatus,  and 
even  wholly  involuntary  contraction  of  the  sphincter,  pinches 
the  inflamed  vein  and  causes  extreme  pain. 

Subcutaneous  rupture  of  these  veins  is  frequently  produced 
by  straining  at  stool  and  other  efforts  that  invoke  marked  fixa- 
tion of  the  abdominal  muscles. 

The  diagnosis  is  easy,  the  thrombotic  pile  appearing  at  the 
anal  margin  as  a  small  purple  tumor  which  is  exquisitely  sensi- 
tive to  the  touch. 

The  treatment  is  simple  and  efficient  if  properly  carried  out 
under  antiseptic  precautions.  A  drop  or  two  of  4  per  cent, 
cocaine  solution  is  thrown  into  the  tumor  immediately  beneath 
the  skin,  and  the  latter  incised  in  a  longitudinal  direction.  This 
incision  relieves  tension  and  the  contained  clot  is  spontaneously 
expelled.  No  squeezing  or  curetting  should  be  done.  The 
anus  is  at  once  covered  with  a  hot  weak  bichloride  compress, 
and  the  same  form  of  dressing  should  be  continued  until  heal- 
ing is  complete,  as  infection  of  the  small  wound  might  prove  to 
be  a  serious  matter  through  extension  upward  along  the  throm- 
bosed vein.  The  bowels  should  be  kept  open  by  mild  laxatives, 
but  cathartics  increase  rather  than  diminish  the  discomfort. 

Persons  predisposed  to  external  hemorrhoids  may  often  fore- 
stall attacks  by  the  absolute  avoidance  of  straining  at  stool  and 


HEMORRHOIDS  517 

by  sponging  the  anus  with  cold  water  instead  of  using  toilet 
paper  after  defecation. 

Internal  Hemorrhoids. — ^Laying  aside  academic  classifica- 
tions, internal  hemorrhoids  can  be  divided  into  two  forms.  The 
common  or  venous  hemorrhoid  is  composed  of  a  bundle  of  vari- 
cose veins  surrounded  by  considerable  quantities  of  connective 
tissue.  The  nutrient  artery  enters  and  the  veins  leave  the 
tumor  at  its  superior  aspect  well  above  the  skin  margin. 

Early  in  the  history  of  this  form  of  hemorrhoid  there  is  con- 
siderable bleeding  from  the  varicosities  of  which  it  is  composed, 
but  attacks  of  inflammation  in  and  about  the  vein  finally  result 
in  the  deposit  of  more  connective  tissue  and  diminution  of  the 
vascularity,  so  that  the  bleeding  may  be  greatly  lessened  or 
abolished. 

The  symptoms  of  which  most  complaint  is  made  are  the  early 
bleeding,  the  attacks  of  inflammation  which  give  rise  to  rather 
severe  pain,  and  the  presence  of  a  protruding  mass  on 
defecation.  The  bleeding  varies  from  a  slight  streaking  of  the 
bowel  passage  with  blood,  to  hemorrhages  so  severe  that  a  high 
grade  of  anaemia  results.  "An  attack  of  piles"  is  the  popular 
synonym  for  a  phlebitis  or  other  inflammatory  process  in  the 
tumor,  which  causes  both  rectal  and  vesical  tenesmus  and  a 
backache  which  extends  down  the  posterior  surface  of  the  thighs. 
This  subsides  in  a  few  days  and  leaves  the  affected  hemorrhoid 
firmer  and  less  vascular  than  before. 

Some  protrusion  is  usual  with  each  act  of  defecation.  If  the 
sphincter  muscles  are  not  irritable  the  hemorrhoids  are  easily 
returned  within  the  anus,  but  a  tightly  contracted  or  irritable 
sphincter  may  retain  them  within  its  grasp  long  enough  to  cause 
strangulation  and  sloughing,  followed  by  a  spontaneous,  although 
long-drawn-out  and  painful  cure. 

Long  duration  of  the  disease  leads  to  involvement  of  the  veins 
external  to  the  sphincter,  when  '^ mixed  hemorrhoids"  is  the 
result. 


5l8      DISEASES    ASSOCIATED    WITH   GYNiECOLOGIC   LESIONS 

Diagnosis. — The  diagnosis  is  so  easy  that  it  is  usually  made  by 
the  patient,  but  all  rectal  affections  unfortunately  are  presumed 
by  the  laity  to  be  hemorrhoids,  and  on  this  account  early 
carcinoma  of  the  rectum  is  universally  overlooked. 

Every  patient  who  complains  of  rectal  symptoms  should  be 
carefully  examined  both  digitally  and  with  the  speculum.  The 
internal  hemorrhoid  is  scarcely  perceptible  to  the  touch,  but  is 
visible  when  the  anus  is  inverted  by  the  finger  in  the  vagina,  and 
upon  the  introduction  of  a  bivalve  or  trivalve  rectal  speculum 
it  is  seen  as  a  bluish  sessile  tumor  which  bleeds  upon  rubbing  its 
surface.  As  a  rule  there  are  a  number  of  tumors  about  the 
circumference  of  the  anus  with  strips  of  healthy  mucosa  between, 
in  which  prolapsed  hemorrhoids  differ  from  prolapse  of  the  rec- 
tum. Cancer  of  the  rectum  is  a  distinct,  hard,  nodular  or  annu- 
lar new  growth,  which  ulcerates  and  does  not  prolapse. 

Very  intense  pain,  aside  from  strangulation  of  the  hemor- 
rhoidal tumors,  is  much  more  suggestive  of  anal  fissure  or  ischio- 
rectal abscess  than  of  hemorrhoids. 

Treatment. — The  treatment  is  either  palliative  or  radical. 
Radical  treatment  is  positively  indicated  for  strangulated  hem- 
orrhoids and  for  those  which  bleed  so  freely  as  to  cause  a  severe 
grade  of  anaemia.  All  others  must  be  treated  radically  if  cure 
is  desired,  but  the  annoyance  so  frequently  is  trifling  that  the 
patient  is  unwilling  to  undergo  operation.  Under  such  cir- 
cumstances much  can  be  done  to  alleviate  the  discomfort  by 
keeping  the  bowels  open,  by  absolute  avoidance  of  straining  at 
stool,  and  the  use  of  cold-water  enemas  and  the  cold  spray;  a 
practical  combination  of  these  being  obtained  by  the  use  of  a 
small  dose  of  cascara  at  night,  a  small  enema  of  cold  water  in  the 
morning  with  immediate  cessation  of  efforts  at  defecation  when 
the  lower  bowel  is  emptied,  the  immediate  replacement  of  the 
tumors,  and  a  cold  douche  to  the  anus  before  leaving 
the  toilet.  Mild  astringents,  such  as  the  distilled  extract 
of  hamamelis,  applied  to  the  protruding  tumors  on  a  pled- 
get of  cotton  before  replacing  them   also  seem  to  be  of  some 


HEMORRHOIDS  519 

benefit,  but  the  very  fussy  applications  of  salves  and  supposi- 
tories are  hardly  worth  the  time  and  trouble  required  for  their 
use. 

Surgical  Treatment. — The  ofhce  treatment  of  hemorrhoids  by 
means  of  hypodermic  injections  into  their  interior  should  be 
left  to  the  rectal  specialist,  who  on  the  grounds  of  a  large 
experience  may  be  able  to  defend  himself  when  disaster  over- 
takes him.  The  gynaecologist  and  surgeon  had  better  confine 
himself  either  to  palliation  or  outspoken  operative  measures. 

Pre-operative  treatment  should  include  a  cathartic  24  hours, 
and  an  enema  four  or  five  hours,  before  operation.  The  enema 
should  be  entirely  removed,  even  if  the  use  of  the  rectal  tube  is 
necessary  for  this  purpose.  The  diet  for  the  preceding  day 
should  be  restricted  to  such  cooked  food  as  leaves  but  little  res- 
idue. Cleansing  and  shaving  should  be  performed  the  night 
before.  The  final  cleansing  should  be  performed  with  soap  and 
water,  washing  this  off  with  sterile  water  followed  by  alcohol, 
and  should  take  place  after  the  patient  is  anaesthetized.  As  the 
operation  frequently  is  performed  in  association  with  plastic 
work,  general  anaesthesia  will  have  been  required  for  that  pur- 
pose, and  in  all  but  the  simplest  cases  it  is  more  satisfactory 
even  when  hemorrhoidectomy  is  done  alone. 

A  word  of  caution  concerning  the  combination  of  abdominal 
and  rectal  operations  may  not  be  out  of  place.  Should  there 
be  any  difficulty  in  opening  the  bowels  after  a  laparotomy,  the 
matter  of  a  sensitive  painful  rectum  is  not  only  annoying  but 
under  some  circumstances  becomes  an  actual  source  of  danger 
by  preventing  the  effectual  use  of  enemas. 

With  the  patient  in  the  lithotomy  position  the  anus  is  slowly 
but  thoroughly  dilated,  paralysis  of  the  sphincters,  but  not 
their  rupture,  being  the  aim.  This  may  be  accompHshed  with 
the  speculum  or  fingers,  preferably  the  latter  as  they  more 
accurately  register  the  degree  of  resistance  remaining.  After 
thorough  dilation  has  been  accomplished  the  hemorrhoids  pro- 
lapse spontaneously  or  can  readily  be  drawn  outside  the  anus. 


520      DISEASES   ASSOCIATED    ^^^TH   GYNECOLOGIC    LESIONS 

A  great  variety  of  methods  has  been  suggested  for  their  removal 
— simple  crushing,  ligature,  the  clamp  and  cautery,  complete 
excision  with  ligature  of  the  vessels  and  repair  of  the  defect, 
and  complete  removal  of  the  pile-bearing  area. 

The  only  one  of  them  to  be  positively  avoided  is  excision 
and  suture,  since  the  rectum  is,  and  always  remains,  a  contami- 
nated area,  and  with  a  number  of  completely  sutured  wounds 
in  such  an  area  some  must  become  infected.     Complete  re- 


FiG.  234. — Hemorrhoidectomy.     "After  thorough  dilatation  the  hemorrhoids 

prolapse  spontaneously." 


moval  of  the  pile-bearing  area  is  a  severe  operation  and  should 
be  reserved  for  the  worst  type  of  cases. 

On  the  whole,  the  clamp  and  cautery  is  the  more  satisfactory 
from  the  standpoint  of  simplicity  and  the  after-pain  is  not  so 
severe  as  from  the  ligature  method. 

Each  tumor  is  picked  up  individually,  its  muco-cutaneous 
margin  incised,  and  the  clamp  so  apphed  that  if  all  were  applied 
simultaneously  their  points  would  meet  in  the  center  of  the 


HEMORRHOIDS 


521 


anus.  Unless  a  non-heat-conducting  clamp  is  at  hand  the  skin 
behind  the  clamp  should  be  protected  by  moist  sponges.  The 
hemorrhoid  is  then  removed  a  short  distance  beyond  the  clamp 
and  the  protruding  stump  charred  with  the  cautery  at  a  dull 
red  heat.  The  clamp  is  opened  slowly  and  if  haemostasis  is 
not  perfect  the  oozing  point  is  again  touched  with^the  cautery. 


Fig.  235. — Hemorrhoidectomy.     "Each  tumor  is  picked  up  individually  and  its 
mucocutaneous  border  incised." 

A  simpler  and  better  method  is  to  burn  away  all  the  pro- 
truding tumor  after  preliminary  incision  of  the  muco-cutaneous 
border  and  clamping. 

In  the  absence  of  a  good  cautery  a  simple  Hgature  method 
consists  in  first  drawing  down  the  tumor  and  snipping  through 
the  muco-cutaneous  junction;  the  pile  is  then  clamped  by  one 
or  two  hasmostats  applied  well  against  its  base  and  in  the 


52  2      DISEASES   ASSOCIATED    WT:TH   GYN.ECOLOGIC   LESIONS 

longitudinal  axis  of  the  body.  A  heavy  thread  is  passed  behind 
the  clamps  so  as  to  perforate  the  pile  base  at  its  middle  and  this 
thread  is  tied  in  both  directions,  the  tying  being  done  as  the  clamp 
is  removed  so  that  the  ligature  lies  in  the  groove  produced  by 
the  instrument.  If  the  tumor  is  very  small  nothing  more  need 
be  done;  if  larger  it  should  be  cut  away  sufficiently  far  from  the 


Fig.  236. — Hemorrhoidectomy.  The  skin  is  protected  by  moist  sponges.  The 
pile  is  crushed  at  its  base  after  incision  of  the  mucocutaneous  border.  The  entire 
tumor  is  removed  by  the  cautery. 

ligature  to  avoid  any  danger  of  the  latter  slipping  off  the  stump. 
All  the  tumors  can  be  removed  by  either  method,  providing 
they  are  all  clamped  longitudinally  and  a  strip  of  normal  mucosa 
is  left  between  the  adjacent  stumps. 

When  the  operation  is  completed  the  anus  should  be  gently 
held  open  to  make  certain  that  active  bleeding  has  been  con- 


HEMORRHOIDS 


523 


trolled,  and  a  strip  of  iodoform  gauze  is  introduced  above  the 
site  of  operation  with  its  outer  end  protruding  through  the 
anus.  This  gives  immediate  warning  of  post-operative  bleeding 
and  keeps  the  stumps  apart. 

The  post-operative  treatment  consists  in  the  use  of  enough 
morphine  hypodermically  to  prevent  extreme  pain  and  spasm 


Fig.  237. — Hemorrhoidectomy.     Clamp  so  applied  that  it  points  toward  the 

center  of  the  anus. 


of  the  sphincters  should  their  paralysis  not  be  complete. 
Catheterization  is  frequently  necessary  but  should  be  avoided 
if  possible. 

After  the  lapse  of  48  hours  a  saline  cathartic  or  a  half  ounce 
of  castor  oil  is  given.  When  the  patient  feels  that  the  bowels 
are  about  to  act,  an  enema  of  sterile  oil  is  administered  through 


524      DISEASES   ASSOCIATED    WITH   GYN^ECOLOGIC   LESIONS 

a  soft  catheter  which  is  introduced  beside  the  gauze,  and  the 
latter  is  expelled  with  the  bowel  motion.  The  anus  is  irrigated 
externally  with  sterile  water,  boric  acid  solution,  or  a  weak 
bichloride  solution  after  each  defecation. 

There  is  sometimes  extreme  swelling  within  a  few  hours  after 
operation,  this  being  proportionate  to  the  force  used  in  dilating. 


Fig.  238. — Hemorrhoidectomy.     It  is  wise  to  char  the  end  of  the  stump  with  the 
cautery  after  the  ligature  operation. 

The  discomfort  so  caused  may  be  markedly  alleviated  by  hot 
moist  dressings  of  normal  saline  or  weak  bichloride  solution. 

The  bowels  should  be  opened  daily  after  the  first  motion  and 
the  oil  enema  may  be  repeated  whenever  necessary. 

The  diet,  at  first  liquid,  is  gradually  increased,  but  the  pain  on 
defecation  is  materially  lessened  if  the  diet  is  somewhat  re- 
stricted until  healing  is  well  advanced. 

The  patient  is  kept  in  bed  until  perfectly  comfortable,  and 


HEMORRHOIDS 


5^5 


should  remain  under  observation  at  least  lo  days,  as  late  bleeding 
occasionally  occurs  after  any  method  of  operation.  While  this 
usually  is  not  dangerous,  it  is  alarming,  and  it  is  far  better  to 
have  the  patient  under  direct  observation  a  day  or  two  longer 
than  necessary  rather  than  have  her  disturbed  by  a  hemorrhage 
after  professional  care  has  ceased. 


Fig.  239. — The  raspberry-like  or  capillary  internal  liemorrhoid. 

The  other  form  of  internal  hemorrhoid  is  a  small  raspberry- 
like growth  occurring  somewhat  above  the  level  of  the  internal 
sphincter.  Its  only  symptom  is  hemorrhage,  the  quantity  of 
blood  lost  being  surprising  when  the  size  of  the  growth  is  con- 
sidered. It  sometimes  requires  prolonged  search  to  locate  this 
capillary  pile,  but  it  always  can  be  found  if  the  knee-chest  pos- 
ture is  assumed  by  the  patient  while  the  short  proctoscope  is  used 
by  the  examiner.     When  found  it  may  be  clamped  and  tied  off 


526      DISEASES   ASSOCIATED    WITH   GYNECOLOGIC   LESIONS 

or  destroyed  by  the  thermo-cautery,  no  especial  after-treatment 
being  required. 

APPENDICITIS 

Both  acute  and  chronic  appendicitis  are  frequently^observed 
by  the  gynaecologist.  The  former  is  often  mistaken  for  acute 
infection  of  the  pelvic  organs  and  vice  versa. 

Chronic  appendicitis  may  produce  distinct  pelvic  symptoms 
when  the  caecum  is  prolapsed,  and  the  retroverted  uterus  is  fre- 
quently the  cause  of  pain  in  the  right  iliac  fossa. 

Acute  Appendicitis. — Acute  appendicitis  is  typically  a  disease 
of  the  second  and  third  decades,  but  no  age  is  exempt  from 
infancy  to  senescence. 

Its  etiology  is  not  always  clear,  but  the  frequency  with  which 
concretions,  strictures,  kinks,  and  bends  are  found,  leads  one  to 
regard  mechanical  insult  and  imperfect  drainage  as  the  common 
provoking  factors,  in  an  organ  whose  blood  supply  is  limited  and 
whose  resistance  is  undoubtedly  lowered  thereby,  as  well  as  by 
its  instability  as  a  vestigal  structure. 

The  constant  presence  of  colon  bacilli  in  the  lumen  of  the 
appendix  provides  the  only  micro-organism  necessary,  but 
staphylococci,  streptococci,  and  the  bacillus  pyocyaneus  are 
many  times  associated  with  it.  Attention  has  recently  been 
called  to  the  possibility  that  anaerobic  bacteria,  not  growing 
on  ordinary  culture  media,  may  be  responsible  for  some  rather 
mysterious  infections  of  portions  of  the  intestinal  tract. 

Pathology. — The  pathological  conditions  found  vary  widely. 
In  the  mildest  cases  there  may  be  only  a  diffuse  inflammation  of 
the  mucous  membrane  with  ecchymotic  spots  scattered  through 
it,  some  oedema  of  the  entire  organ,  and  a  little  injection  of  its 
peritoneal  covering. 

In  other  instances  there  may  be  occlusion  of  the  appendix 
with  inflammation  of  that  portion  distal  to  the  stricture  and 
suppuration,  the  pus  being  confined  to  the  interior  of  the 
occluded  portion.     In  stillothers,  gangrene,  which  is  limited  to 


ACUTE   APPENDICITIS 


527 


the  mucosa  of  a  small  area  results  in  an  ulcer  which  may  extend 
through  the  mucosa,  or  through  all  the  coats  and  produce  a 
perforation.  Occasionally  one  finds  a  very  minute  ulcer  in  the 
appendix  of  a  patient  whose  symptoms  have  been  so  marked 
that  the  relationship  existing  between  the  lesion  and  the  symp- 
toms seems  distinctly  out  of  proportion.  An  analogous  condi- 
tion is  sometimes  found  in  the  urethra  of  male  patients  who 
have  "urethral  fever"  after  the  passage  of  a  sound  or  catheter. 

Total   gangrene   of   the   appendix  is   sometimes   seen,    the 
whole  organ  presenting  the  appearance  of  a  sloughing  piece  of 


Fig.  240. — Acute    appendicitis.     Appendix    occluded    near    coecum    at    point 
clamped.     Entire  appendix  distal  to  this  point  distended  with  pus. 


tissue,  and  partial  gangrene  is  very  common.  The  limited  blood 
supply  to  the  appendix  explains  the  early  and  frequent  occur- 
rence of  gangrene  when  the  circulation  is  interfered  with  by 
thrombosis  of  the  artery  of  the  meso-appendix  or  any  of  its 
branches. 

Perforation  and  gangrene  lead  inevitably  to  peritoneal  infec- 
tion, but  this  also  may  occur  from  migration  of  microorganisms 
through  the  intact  but  inflamed  wall  of  the  appendix. 

Slow  perforation,  gangrene  of  small  areas,  and  infection 
through  the  intact  wall,  cause  limited  peritoneal  involvement 


528      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC  LESIONS 

because  adhesions  form  ahead  of  the  lesion.  Sudden  and  com- 
plete perforation,  and  total  gangrene,  lead  to  wide  contamination 
of  the  peritoneal  cavity  with  subsequent  inflammation,  the 
pouring  out  of  large  quantities  of  peritoneal  serum,  general  peri- 
tonitis, and  widespread  suppuration. 

Localized  abscess  formation  also  is  frequent  if  appendicular 
infection  lasts  more  than  48  hours.     In  most  cases  the  abscess 


Fig.  241. — Drawing  from  specimen  of  early  gangrene  of  the  appendix  with  two 

perforations. 


contains  the  appendix,  either  in  its  cavity  or  forming  a  portion 
of  its  wall.  A  localized  abscess  may  be  residual  and  follow 
peritonitis  when  it  may  be  some  distance  from  the  original 
source  of  infection,  or  it  may  be  a  gravitation  abscess  produced 
by  the  gradual  accumulation  of  products  of  inflammation  at 
the  bottom  of  the  pelvic  cavity. 

It  is  by  no  means  rare  to  find  a  normal-appearing  appendix 


ACUTE   APPENDICITIS  529 

in  or  about  an  old  abscess,  the  appendix  itself  having  under- 
gone complete  resolution  while  pus  continued  to  accumulate 
around  it. 

The  character  of  the  wall  surrounding  an  appendicular  ab- 
scess differs  according  to  its  location.  It  may  be  composed 
entirely  of  intestine  and  inflammatory  exudate,  or  intestine 
and  exudate  may  lie  to  the  median  side  with  parietal  peritoneum 
laterally.  When  the  appendix  is  retro-peritoneal,  the  posterior 
surface  of  the  caecum  and  ascending  colon  form  the  anterior 
abscess  wall,  the  lateral  walls  being  bounded  by  the  peritoneum 
as  it  leaves  the  colon. 

A  gangrenous  area  upon  the  caecum  or  other  portion  of  the 
intestine  is  not  uncommon,  and  should  the  patient  live  suffi- 
ciently long  this  becomes  a  perforation  through  which  the  ab- 
scess will  open.  Enlarged  mesenteric  glands  are  frequently 
found  both  in  the  meso-appendix  and  the  retro-colic  chain. 

Symptoms. — Pain  is  the  first  symptom  of  acute  appendicitis, 
and  it  is  present  throughout  the  entire  course  of  the  disease  ex- 
cepting during  the  first  few  hours  after  total  gangrene  of  the 
organ. 

The  early  pain,  almost  without  exception,  is  referred  either 
to  the  epigastric  or  para-umbilical  region.  The  early  pain  is 
likely  to  be  more  severe  than  that  which  is  present  later  unless 
widespread  virulent  peritonitis  results,  and  its  reference  to  the 
epigastric  and  umbilical  regions,  as  well  as  its  severity,  leads 
one  to  believe  that  it  is  due  to  a  true  appendicular  colic  from 
distension  of  the  appendix  rather  than  the  inflammatory 
process  itself.  After  the  lapse  of  a  few  hours  the  pain  becomes 
locaKzed  in  the  right  iliac  fossa,  its  point  of  greatest  intensity 
more  often  being  at  McBurney's  point  than  any  other  one  place. 
However,  this  latter  pain  which  is  distinctly  inflammatory  in 
origin,  may  be  to  the  left  of  the  median  line,  low  in  the  pelvis, 
near  the  inguinal  ligament,  in  ^the  right  renal  region,  or 
at  the  costal  margin  anteriorly.  The  early  pain  is  inter- 
mittent, or  more  precisely  remittent,  while  the  later  pain  is 

34 


530      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC   LESIONS 

constant  in  its  character.  Acute  exacerbations  of  pain  after 
the  first  day  or  two  are  chiefly  due  to  the  spread  of  the  infection 
from  its  original  source. 

Nausea  and  Vomiting. — Reflex  nausea  and  vomiting,  while 
not  so  constant  as  pain,  are  nevertheless  almost  universally 
present.  Sometimes  there  is  but  one  attack  of  vomiting  which 
comes  on  soon  after  the  onset  of  pain  and  does  not  recur,  unless, 
or  until,  peritonitis  becomes  a  marked  feature  of  the  disease. 
The  vomited  material  consists  of  the  stomach  contents,  and  it 
is  this  which  leads  to  the  almost  universal  diagnosis  of  ''acute 
indigestion"  at  the  outset  of  an  acute  attack  of  appendicitis. 
A  chill  is  rarely  observed  at  any  time  during  the  course  of  the 
disease.  It  is  of  no  especial  importance  when  it  does  occur, 
unless  it  be  to  awaken  the  patient  and  her  physician  to  the  fact 
that  something  really  serious  is  taking  place. 

Fever  is  rarely  absent  after  the  first  few  hours,  but  as  a  rule 
with  few  exceptions  it  does  not  come  on  until  after  both  pain  and 
vomiting  have  occurred,  a  fact  whose  significance  was  pointed 
out  by  Murphy.  Several  facts  regarding  the  temperature  in 
appendicitis  need  emphasizing,  the  first  being  that  mouth 
temperature  is  always  unreliable  because  the  dry  tongue  inter- 
feres with  the  correct  action  of  the  thermometer,  and  thirst 
leads  to  the  constant  drinking  of  cold  water  which  changes  the 
temperature  of  the  mouth  for  the  time  being.  The  temperature, 
therefore,  always  should  be  taken  per  rectum.  The  second 
is  that  the  degree  of  fever  bears  no  known  relation  to 
the  severity  of  the  disease.  Many  a  patient  with  appendicitis 
has  gone  to  an  untimely  grave  because  the  temperature  was 
not  alarmingly  high.  A  high  temperature  may  persist  for  a  day 
or  two  followed  by  complete  recovery,  while  only  a  trifling  eleva- 
tion may  be  present  in  a  fatal  attack.  The  pulse  usually  corre- 
sponds somewhat  to  the  degree  of  fever  present,  but  in  virulent 
cases  the  temperature  may  be  but  slightly  elevated  while  the 
pulse  is  almost  uncountable.  The  rate  and  character  of  the 
pulse  are  far  less  likely  to  be  misleading  than  the  temperature. 


ACUTE   APPENDICITIS  53 1 

Constipation  is  the  rule  at  the  outset  although  an  occasional 
attack  begins  with  diarrhea. 

Bladder  irritation  may  be  complained  of  when  the  caecum 
and  appendix  are  so  prolapsed  that  adhesions  to  the  bladder  form 
or  infection  of  its  peritoneal  coat  occurs. 

The  leucocyte  count  is  increased  in  all  but  the  most  virulent 
attacks.  While  the  relationship  between  leucocytosis  and  the 
severity  of  infection  is  no  more  constant  here  than  elsewhere,  it 
does  provide  a  rough  basis  for  estimating  the  latter,  a  leucocyte 
count  as  low  as  12  or  15  thousand  rarely  being  present  with 
gangrene  or  free  perforation,  while  one  of  more  than  30  thou- 
sand always  calls  attention  to  the  possibility  of  pulmonary 
compHcations. 

On  physical  examination  some  tympany  is  usually  found  after 
peritoneal  involvement  has  taken  place,  but  this  is  not  constant 
in  the  early  hours. 

Tenderness  upon  pressure,  likewise,  always  is  present  when 
the  peritoneum  is  involved  and  usually  before  this  time,  but  a 
pelvic  appendix  may  escape  pressure  appHed  through  the  anterior 
abdominal  wall.  Pain  in  the  right  iliac  fossa  is  often  elicited 
by  pressure  on  the  other  side  of  the  abdomen,  and  pain  upon 
sudden  withdrawal  of  the  examining  hand  is  usually  more  severe 
than  that  caused  by  pressure. 

Hyperaesthesia  of  the  skin  and  rigidity  of  the  abdominal 
muscles  to  the  right  of  the  mid-line,  more  especially  rigidity, 
are  among  the  most  important  diagnostic  signs,  and  their  signifi- 
cance is  due  to  the  fact  that  no  matter  where  the  appendix  may 
lie  its  nerve  supply  is  always  the  same;  consequently  the  mus- 
cular rigidity  (before  involvement  of  the  parietal  peritoneum) 
is  always  in  the  same  place.  Rigidity  corresponds  more  nearly 
to  the  area  about  McBurney's  point  than  does  pain  or  deep 
tenderness  to  pressure. 

Rigidity  which  is  most  marked  halfway  between  the  umbiKcus 
and  anterior-superior  spine,  which  shades  off  imperceptibly  at 
the  costal  margin  superiorly,  at  the  left  rectus  laterally,  and 


532      DISEASES    ASSOCIATED    WITH   GYNECOLOGIC   LESIONS 

above   the  pubes  inferiorly,   is   rarely   due   to   anything  but 
appendicitis. 

On  percussion  during  the  first  hours  of  appendicitis  no  appre- 
ciable change  may  be  found;  later  more  marked  tympany  may 
be  made  out  over  the  abdomen  generally,  and  local  dullness  may 
possibly  be  present  in  the  right  side.  Even  over  an  abscess 
there  may  be  a  marked  tympanitic  note  from  the  presence  of  gas 
within  its  cavity. 


Fic.  242. — An  appendicular  abscess  may  give  a  tympanitic  note  on  percussion 
from  the  formation  of  gas  clue  to  the  activities  of  the  colon  bacillus. 

A  distinct  palpable  mass  can  be  found  in  the  right  iliac 
fossa  if  local  peritonitis  about  an  infected  appendix  has  existed 
for  many  hours,  but  the  palpable  mass  is  a  late,  not  an  early 
development,  and  means  that  peritoneal  exudate  has  been 
poured  out  in  appreciable  quantities,  and  that  sufficient  time 
has  elapsed  for  solidification  of  the  exudate  and  matting  to- 
gether of  the  viscera. 


ACUTE   APPENDICITIS  533 

On  vaginal  examination  the  mobility  of  the  uterus  is  not 
lessened  in  the  early  stages,  but  the  frequent  association  of 
pelvic  peritonitis  and  gravitation  abscess  with  appendicitis,  may 
fix  the  uterus  later  in  the  disease.  Appreciable  swelling  is 
rarely  found  in  the  early  stages  although  a  mass  may  appear 
later,  either  upon  the  right  side  or  in  the  recto-uterine  excava- 
tion. Rectal  examination  in  women  ordinarily  only  confirms 
the  vaginal  findings,  and  while  it  should  not  be  neglected  it 
throws  no  new  light  upon  the  diagnosis. 

Clinical  Course  and  Progress  of  Acute  Appendicitis. — There 
is  no  typical  or  even  average  course  pursued  by  appendicitis, 
the  attacks  varying  from  the  very  mildest  which  last  only  a 
day  or  two,  to  those  of  extreme  severity,  with  gangrene,  rapid 
widespreading  peritonitis,  and  death  within  a  few  days. 

It  is  altogether  probable  that  mild  attacks  are  much  more 
common  than  we  have  suspected,  and  this  is  especially  true  in 
children  whose  attacks  of  ''acute  indigestion"  are  of  ten  attacks 
of  appendicitis  of  a  mild  character. 

The  mildest  cases  of  acute  appendicitis  may  present  symp- 
toms which  last  but  a  few  hours.  There  is  some  pain,  one  or 
two  vomiting  spells,  and  a  trivial  elevation  of  temperature,  but 
the  palpatory  findings  are  entirely  negative  excepting  as  regards 
rigidity. 

Other  cases,  with  a  slowly  forming  perforation  or  infection 
through  the  intact  wall  of  the  appendix,  develop  more  severe 
symptoms,  and  there  is  evidence  of  localized  peritonitis  with  the 
evolution  of  a  palpable  mass  which  may  undergo  complete 
resolution  or  in  which  an  abscess  may  develop. 

Even  with  the  development  of  an  abscess,  recovery  is  still 
possible  without  surgical  interference  through  perforation  into 
the  intestine  and  spontaneous  drainage. 

Gangrene  of  the  whole  organ  or  wide  open  large  perforation 
may  cause  general  peritonitis  and  death.  Inflamed  retro-cecal 
appendices  very  often  lead  to  secondary  involvement  of  the 


534      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC   LESIONS 

lung,  to  pyelo-phlebitis,  and  to  sub-phrenic  abscess,  all  of  which 
are  desperate  and  frequently  fatal  complications. 

On  the  whole,  the  exact  mortality  rate  of  acute  appendicitis 
is  unknown.  There  is  no  justification  for  the  belief  of  many 
surgeons  that  most  cases  would  die  if  not  operated  upon,  but 
there  is  less  justification  for  a  waiting  policy,  which  condemns 
many  to  recurring  attacks,  fecal  fistulae,  and  prolonged  conva- 
lescence. There  is  no  surgical  disease  in  which  the  symptoms 
and  physical  signs  convey  so  little  knowledge  of  the  ultimate 
outcome  as  acute  appendicitis,  those  cases  which  seem  to  be  very 
mild  often  terminating  disastrously,  and  those  with  the  severest 
possible  onset  recovering  in  a  surprisingly  short  time. 

Diagnosis. — Acute  appendicitis  is  so  common  that  virtually 
every  known  disease  which  causes  acute  abdominal  pain  and  fever 
has  been  mistaken  for  it  at  one  time  or  another.  Practically, 
in  every  patient  presenting  the  above  symptoms  one  must  think 
of  the  following:  pleurisy,  pneumonia,  gastro-enteritis,  ileo- 
colitis, intestinal  obstruction,  cholecystitis,  cholelithiasis,  tubal 
pregnancy,  salpingitis,  oophoritis,  torsion  of  the  pedicle  of  an 
ovarian  tumor,  Dietl's  crisis,  and  renal  calculus. 

Both  pleurisy  and  pneumonia  are,  in  young  subjects,  frequently 
accompanied  by  abdominal  pain,  vomiting,  and  tympany,  and 
both  may  present  cutaneous  abdominal  hyperaesthesia  and 
some  rigidity. 

In  pleurisy  the  friction  rub  is  so  perceptible  as  not  to  be  over- 
looked if  examined  Jor.  Central  pneumonia  may  be  present  in 
children  with  no  demonstrable  physical  evidences  in  the  chest, 
but  the  rapid  respiration  of  pneumonia  and  its  disturbed  pulse- 
respiration  ratio  has  no  counterpart  in  acute  appendicitis.  A 
leucocyte  count  of  upward  of  30  thousand  should  always  lead 
to  a  suspicion  of  pneumonia. 

Ileo-colitis  in  young  children  is  so  much  more  frequent  than 
appendicitis  that  the  latter  many  times  is  overlooked. 

Diarrhea,  especially  if  the  bowel  passages  are  blood-stained, 
should   lead    one    to    suspect   ileo-colitis    or   intussusception. 


ACUTE   APPENDICITIS  535 

Vomiting  preceding  the  onset  of  pain  is  suggestive  of  gastro-en- 
teritis  rather  than  appendicitis,  and  fever  preceding  either  vom- 
iting or  pain,  while  it  does  not  exclude  appendicitis,  puts  it  out 
of  the  range  of  probability. 

In  many  cases  of  acute  gastro-enteritis,  colitis,  etc.,  the  abdo- 
men is  tympanitic,  but  it  is  not  rigid. 

In  any  case  of  suspected  appendicitis  in  which  pneumonia, 
gastritis,  enteritis,  or  colitis  cannot  be  excluded,  it  is  much  wiser 
to  make  a  tentative  diagnosis  only,  since  delay  for  a  few  hours  is 
rarely  dangerous  in  appendicitis,  while  an  operation  which  re- 
veals a  normal  appendix,  in  a  patient  who  has  pneumonia,  is 
nothing  less  than  a  catastrophe. 

Intestinal  obstruction  is  frequently  mistaken  for  appendicitis. 
As  both  are  surgical  conditions  a  mistake  is  fraught  with  no 
danger  to  the  patient  if  the  operator  is  competent  to  deal  with 
either.  Violent  peristalsis  is  never  present  in  appendicitis. 
On  the  contrary,  while  gurgling  may  be  appreciable,  peristalsis 
is  less  than  normal.  The  material  vomited  in  uncomplicated 
appendicitis  is  not  intestinal,  and  enemas  are  effectual  in  causing 
the  expulsion  of  flatus. 

The  pelvic  disorders  w^hich  simulate  appendicitis  have  been  dis- 
cussed under  their  appropriate  heads.  Their  exclusion  is  some- 
times impossible  but  an  attempt  should  always  be  made  to  estab- 
lish a  positive  diagnosis.  Any  error  in  diagnosis  should  be  in 
favor  of  appendicitis  and  operation,  as  it  is  only  in  salpingo-ooph- 
oritis  that  operation  during  the  acute  stage  is  not  advisable. 

Lesions  of  the  kidney  and  ureter  always  need  consideration. 
The  kinked  pedicle  of  a  ptosed  kidney,  or  the  obstruction  pro- 
duced by  a  calculus  in  the  right  ureter,  may  cause  right-sided 
abdominal  pain,  vomiting,  and  fever,  and  the  pain  comes  ^r5/ 
as  in  appendicitis.  Bladder  tenesmus  may  be  present  both  in 
appendicitis  and  kidney  lesions,  but  is  less  marked  in  the  former. 
Bloody  urine  is  very  rare  in  acute  appendicitis,  and  the  sudden 
development  of  a  tumor  points  strongly  to  acute  hydronephrosis 
rather  than  appendicitis. 


536      DISEASES   ASSOCIATED    WITH   GYNECOLOGIC   LESIONS 

In  doubtful  cases  the  X-ray  should  be  used  in  order  to  exclude 
kidney  lesions.  While  those  mentioned  are  surgical  disorders  it 
is  a  blunder  to  operate  upon  them  during  the  acute  stage,  and  a 
mistake  may  necessitate  two  incisions  and  a  prolonged  operation 
instead  of  the  simple  appendectomy,  which  the  patient  was 
promised. 

Gall-bladder  disease  usually  gives  rise  to  more  severe  pain 
than  appendicitis,  the  pain  is  higher  in  the  abdomen,  rigidity 
is  marked  just  below  the  ninth  costal  cartilage  and  lessens  as 
one  palpates  toward  the  region  of  the  appendix.  A  chill  is  far 
more  common  in  cholelithiasis  and  the  temperature  may  fluctu- 
ate widely  within  a  few  hours.  In  cholelithiasis  without  pus 
leucocytosis  is  not  at  all  marked,  but  a  suppurating  or  gangren- 
ous gall-bladder  is  productive  of  leucocytosis  as  is  appendicitis. 
While  the  age,  physique,  and  history  of  the  patient  may  present 
nothing  decisive,  they  still  have  their  weight  in  determining 
the  preponderance  of  evidence.  Gall-bladder  disease  is  common 
in  stout  women  who  have  borne  many  children,  while  neither  of 
these  has  any  apparent  effect  upon  the  incidence  of  appendicitis. 

Treatment. — There  is  but  one  proper  treatment  for  appendicitis 
in  its  early  stages,  and  that  is  operation.  One  operates,  not 
because  all  the  patients  would  die  if  unoperated,  but  because  it 
is  impossible  to  determine  which  one  will.  Skillful  operation 
within  48  hours  of  the  onset  will  save  practically  every  patient, 
and  it  may  be  said  with  but  little  exaggeration  that  if  an  occa- 
sional one  dies  at  this  time,  that  one  was  doomed  from  the 
outset.  Early  operation  is  practically  without  danger;  there 
is  no  late  abscess  formation,  no  widespread  infection,  no  septic 
pneumonia,  no  fecal  fistula,  no  secondary  operation,  and  no 
recurrence. 

Again,  there  is  no  dispute  regarding  the  propriety  of  operation 
after  a  localized  abscess  has  formed,  whether  in  the  right  iliac 
fossa,  behind  the  caecum,  or  in  the  pelvis.  That  the  abscess 
should  be  opened  is  undoubted.  The  advisabihty  of  operating 
during  the  stage  of  diffuse  peritonitis  has  been  seriously  ques- 


ACUTE    APPENDICITIS  537 

tioned  by  Ochsner  and  others,  who  prefer  to  treat  the  dis- 
ease medically  at  this  stage  and  await  what  is  considered 
to  be  the  more  favorable  time,  that  of  well-walled-off  abscess 
formation. 

The  author  has  never  seen  a  case  in  which  it  did  not  seem 
that  the  earlier  surgical  intervention  was  practised  the  better, 
excepting  only  those  in  whom  the  peritonitis  was  so  severe 
or  toxaemia  so  profound  that  anaesthesia  was  dangerous. 
This  is  usually  revealed  by  a  quiet  universally  distended  belly, 
the  intestinal  coils  sometimes  showing  plainly  beneath  the 
abdominal  wall,  a  rapid  thready  pulse,  leaky  skin,  and  cyanosed 
extremities.  Here  the  trifling  shock  of  anaesthesia  and  even 
a  short  operation  might  destroy  the  only  possible  hope  of 
recovery. 

With  this  exception,  the  best  rule  to  follow  is  to  operate  at 
once  upon  any  case  which  is  severe  enough  to  be  positively 
diagnosed.  This  does  not  mean  hurried  hasty  operation  with 
lack  of  skilled  assistance  and  with  improper  technique,  nor 
does  it  mean  that  a  bungling  operation  is  better  than  no  opera- 
tion, for  such  is  not  the  case.  Sufficient  time  can  always  be 
taken  to  make  the  diagnosis  reasonably  sure,  to  secure  a  skilled 
surgeon,  to  send  the  patient  to  a  well-equipped  hospital  if  in 
the  city  or  adequately  prepare  for  operation  in  the  country. 
If  these  things  cannot  be  done  the  patient  is  safer  under  medical 
treatment. 

It  has  been  denied  that  there  is  any  medical  treatment  for 
acute  appendicitis.  While  it  is  true  that  drugs,  aside  from 
opium,  are  of  no  value,  the  general  management  of  a  patient 
until  such  time  as  operation  can  be  performed  in  an  operative 
case,  or  throughout  the  disease  if  operation  is  rejected,  or  during 
the  stage  of  acute  toxaemia,  is  of  great  importance. 

The  cardinal  principles  of  such  treatment  are : 

1.  Rest  in  bed.  Diffusion  of  infection  may  follow  moving 
about. 

2.  The  avoidance  of  narcotics  until  the  diagnosis  is  made. 


538      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC   LESIONS 

Afterward  they  do  no  harm  in  the  small  amounts  needed  to 
relieve  pain  and  quiet  peristalsis. 

3.  Avoid  purgation.  There  is  absolutely  no  virtue  in  pur- 
gation excepting  that  it  empties  the  bowel,  and  this  can  be 
accomplished  with  enemas.  Only  too  often  .purgation  empties 
the  bowel  into  the  abdominal  cavity  through  a  wide  open  perfora- 
tion of  the  appendix,  or  a  caecum  from  which  the  appendix  has 
sloughed.  When  an  abscess  has  formed,  purgation  may  rup- 
ture its  wall  and  scatter  pus  widely  through  the  abdominal 
cavity,  and  in  the  earliest  stages  of  peritoneal  involvement, 
violent  peristalsis  disseminates  infection  by  dragging  the  small 
intestine  from  one  part  of  the  abdomen  to  another.    - 

Very  often  the  apparent  improvement,  which  has  manifested 
itself  immediately  after  the  cathartic  has  acted,  is  succeeded  in 
a  few  hours  by  an  exacerbation  of  pain,  tympany,  and  fever. 
If  this  is  met  by  another  dose  of  calomel  and  salts,  and  the  purg- 
ing is  repeated  with  every  exacerbation,  it  is  not  surprising 
that  the  patient  finally  succumbs. 

4.  Keep  the  stomach  free  from  food.  Food  does  not  digest 
under  these  circumstances  and  its  ingestion  stimulates  intes- 
tinal peristalsis.  Cold  water  also  stimulates  peristalsis  but. 
hot  has  less  effect.  The  use  of  the  stomach  tube  and  entire  ab- 
stinence from  water  and  food,  as  advocated  by  Ochsner,  is 
impossible  of  accomplishment  outside  of  a  well- disciplined 
hospital,  but  abstinence  from  food  is  the  most  important  feature 
of  this  regime  and  can  usually  be  brought  about  if  hot  water  in 
small  amounts  is  allowed  frequently. 

5.  Keep  down  painful  distension  of  the  colon  by  the  use  of 
the  rectal  tube,  daily  enemas,  or  colon  lavage  if  paralytic  ileus 
threatens.  Whether  local  applications  to  the  abdomen  have 
any  influence  over  the  course  of  the  disease  is  open  to  some  ques- 
tion, but  that  they  relieve  pain  is  undoubted.  An  ice-bag 
over  the  right  iliac  fossa  sometimes  renders  the  use  of  opiates 
unnecessary,  and  it  should  be  avoided  before  a  diagnosis  is 
made,  for  the  same  reason,  and  used  after  diagnosis,  also  for  the 


CHRONIC   APPENDICITIS 


539 


same  reason.  Poultices  agree  better  with  some  patients,  but 
they  are  mussy  and  disagreeable  and  the  same  effect  can  be 
obtained  by  the  use  of  flannel  wrung  out  of  hot  water  and  kept 
hot  with  the  hot-water  bag  or  electric  pad. 

Such  are  the  palliative  measures  which  will  assist  nature  to 
battle  successfully  with  the  disease  when  surgery  is  deferred 
or  declined. 

CHRONIC    APPENDICITIS 

The  term  chronic  appendicitis  is  used  in  a  very  loose  fashion 
and,  as  popularly  understood,  covers  not  only  true  hyperplasia 


^ 

5fc> 

j£lF         '    i^ 

"^ 

\.       Jf 

•^^^1k 

^^   X^-^JL__ 

-■'»%5'-- 

-i 

• 

f,   A 

Fig.    243. — Chronic  ob- 
literative  appendicitis. 


Fig.  244. — Chronic  appendicitis.     Ob- 
literation of  distal  extremity. 


of  the  connective  tissue  of  the  appendix  with  gradual  contrac- 
tion and  obliteration  of  its  lumen,  but  also  adhesions  resulting 
from  previous  acute  attacks,  defective  drainage  due  to  kinks 
and  strictures,  appendicular  colic  from  concretions,  and  mild 
recurrent  attacks  of  acute  infection. 

It  is  decidedly  doubtful  whether  the  first  of  these,  which  is 
the  only  one  that  may  be  considered  as  a  distinct  pathological 
entity,  is  ever  responsible  for  symptoms.  Morris  of  New  York 
has  attempted  to  prove  for  it  a  distinctive  sort  of  pain,  but  many 


540      DISEASES   ASSOCIATED    WITH    GYNECOLOGIC    LESIONS 

of  his  admirers  have  been  unable  to  distinguish  anything  char- 
acteristic, and  as  often  as  not  one  stumbles  on  one  of  these 
appendices  when  operating  for  other  lesions,  without  a  single 
symptom  having  called  attention  to  the  appendix. 

The  etiology  of  the  other  conditions,  as  well  as  their  pathology, 
is  sufficiently  suggested  by  their  description.  It  is  doubtful 
whether  they  can  be  correctly  termed  chronic  appendicitis  at  all, 
and  it  seems  more  likely  that  the  symptoms  complained  of  are 


Fig.  245. — Chronic  appendicitis  with  communicating  mesenteric  cyst. 

due  to  a  low-grade  recurrent  acute  infection.  Clinically,  how- 
ever, their  course  is  chronic  and  they  must  be  so  described  in 
order  to  be  understandable. 

Chronic  tuberculous  appendicitis  may  be  "sui  generis'^  an 
appendicular  lesion,  or  it  may  be  secondary  to  tuberculosis  of 
the  tubes,  or  a  part  of  a  general  tuberculous  peritonitis;  when 
tuberculous  appendicitis  exists  as  an  independent  lesion  the  diag- 
nosis of  chronic  appendicitis  is  likely  to  be  made  without  any 
definite  idea  as  to  the  causative  micro-organism.  When  asso- 
ciated with  tuberculosis  of  the  pelvic  organs  or  with  general 


CHRONIC   APPENDICITIS 


541 


tuberculous  peritonitis,  the  condition  of  the  appendix  is  of  minor 
interest  save  from  the  standpoint  of  its  etiological  relationship 
to  the  more  widespread  disease.  There  are  clinicians  of  good 
repute  who  feel  that  tuberculous  peritonitis  is  more  Hkely 
to  have  originated  in  the  appendix  or  tubes  than  in  any  other 
abdominal  structures. 

Symptoms. — Pain  about  the  umbilicus  and  in  the  epigastrium 
is  the  symptom  which  most  frequently  sends  the  patient  to  the 
physician.  Intractable  so-called  dyspepsia  or  indigestion, 
which  really  consists  of  epigastric  distress  and  belching  of  gas 


Fig.  246. — Chronic  appendicitis.  Tubercles  on  peritoneal  surface. 

after  the  taking  of  food,  is  much  more  frequent  than  pain  re- 
ferred to  the  right  iliac  fossa. 

It  is  open  to  question  whether  this  epigastric  pain  is  due  to 
any  actual  occurrence  in  the  epigastrium,  but  there  is  at  least 
a  probability  that  it  is  caused  by  pyloric  spasm. 

Occasionally  there  is  vomiting  some  hours  after  taking  food. 

Constipation  is  more  frequent  than  diarrhea,  but  this  is 
true  in  individuals  who  are  otherwise  well. 

Patients  with  low  grade  but  persistent  infecton  of  the  ap- 
pendix often  complain  of  a  feeling  of  weakness  or  malaise,  which 
may  be  attributable  either  to  the  ever  present  or  frequently  re- 
curring discomfort  and  the  anxiety  to  which  its  unknown  origin 


542      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC   LESIONS 

gives  rise,  or  to  a  constant  toxaemia  arising  from  the  infection. 

The  temperature  is  normal  unless  taken  during  one  of  the 
exacerbations  when  it  may  be  found  a  trifle  elevated.  The 
pulse  is  normal,  sometimes  slow  if  there  is  a  coincident  chronic 
infection  of  the  bile  tract. 

In  all  forms  of  chronic  appendicitis  excepting  the  tuberculous 
the  leucocyte  count  is  quite  persistently  a  trifle  above  normal, 
the  differential  count  showing  no  deviation  from  the  ordinary. 
Palpation  of  the  abdomen  may  reveal  no  sensitiveness  if  the 
appendix  is  retro-cecal  or  pelvic,  but  as  a  rule  a  hypersensitive 
point  is  made  out  halfway  between  the  umbilicus  and  anterior- 
superior  iliac  spine.  Comparison  should  always  be  made 
between  the  right  and  left  sides  as  the  abdominal  wall  of  some 
patients  is  always  hypersensitive,  and  the  patient  herself  may 
be  unduly  open  to  the  suggestion  of  pain.  Deep  pressure  with 
the  ends  of  the  fingers  will  elicit  evidence  of  discomfort  in  any 
but  the  most  phlegmatic  normal  individual,  so  that  something 
more  than  a  normal  reaction  to  pressure  is  needed  to  establish 
the  fact  of  a  hypersensitive  area. 

Protective  abdominal  rigidity  over  the  right  side  is  usually 
found,  although  it  may  be  so  trifling  as  to  be  overlooked  unless 
carefully  sought. 

Diagnosis. — Protracted  symptoms  of  chronic  appendicitis 
with  a  localized  mass  on  deep  palpation  should  lead  to  a 
suspicion  that  the  appendicular  infection  is  tuberculous  in  its 
nature.  If  every  acute  disease  producing  abdominal  pain  and 
fever  has  been  mistaken  for  acute  appendicitis,  then  it  is  like- 
wise true  that  every  persistent  pain  in  the  abdomen  has  been 
diagnosed  as  chronic  appendicitis,  and  conversely  chronic 
appendicitis  has  been  called  everything  from  ''ovarian  disease" 
to  dyspepsia. 

Retroversion  of  the  pelvic  disorders,  floating  kidney,  mucous 
colitis  and  peri-colitis  of  the  abdominal  diseases,  need  the 
most  attention.  Retroversion  and  lesions  of  the  right  tube  and 
ovary  are  readily  excluded  if  a  careful  examination  is  made. 


APPENDECTOMY  543 

Floating  kidney  is  easily  found  if  examined  for  with  the 
patient  lying  well  over  on  the  opposite  side.  Mucous  coHtis  is 
revealed  by  the  cohcky  pain,  which  is  followed  by  the  expulsion 
of  large  quantities  of  mucus,  and  peri-coKtis  is  suggested  by  a 
palpable  caecum  that  hardens  under  the  hand,  and  from  which 
gas  is  expelled  with  a  gurgling  sound. 

The  presence  of  any  of  these  disorders  does  not  exclude  ap- 
pendicitis as  it  may  co-exist  with  any  or  all  of  them.  Other 
conditions,  such  as  ptosis  of  the  caecum  with  pelvic  adhesions, 
ureteritis  and  ureteral  calculus,  cholehthiasis,  etc.,  must  be 
considered,  but  on  the  whole  the  diagnosis  of  chronic  appendi- 
citis is  most  conclusively  made  by  ruHng  out  pelvic  disease, 
floating  kidney,  and  mucous  coHtis,  and  having  remaining  a 
history  of  chronic  ''dyspepsia,"  epigastric  discomfort,  and 
tenderness  and  rigidity  in  the  right  ihac  fossa.  Spontaneous 
pain  in  the  right  ihac  fossa  alone,  not  referred  either  to  the 
epigastrium  or  umbiHcal  region,  is  more  frequently  than  other- 
wise not  due  to  chronic  appendicitis. 

An  occasional  error  in  diagnosis  is  inevitable  and  must  be 
met  at  the  operating  table,  but  errors  in  diagnosis  are  infre- 
quent in  proportion  to  the  care  taken  in  examination. 

Treatment. — In  distinction  from  acute  appendicitis  there  is 
no  medical  treatment  for  the  chronic  type.  Strictures  cannot 
be  overcome,  concretions  removed,  adhesions  absorbed,  or 
connective-tissue  contractions  prevented,  by  any  known  drug. 
The  most  that  can  be  done  is  to  insure  that  the  bowels  are  in 
good  order,  and  that  attacks  of  true  acute  indigestion  and  diar- 
rhea do  not  cause  sudden  swelling  with  complete  obstruction 
of  the  lumen  of  the  appendix. 

Persistent  symptoms  due  to  chronic  appendicitis  can  be 
overcome  only  by  the  removal  of  the  appendix. 

APPENDECTOMY 

The  location  and  character  of  the  incision  to  be  made  will 
depend  upon  the  judgment  of  the  operator.        ^ 


544      DISEASES    ASSOCIATED    WITH   GYNECOLOGIC   LESIONS 


If  pelvic  work  must  be  done  at  the  same  time,  the  median 
incision  or  one  low  in  the  right  rectus  had  best  be  chosen,  as 
through  it  any  appendix  can  be  removed  which  is  not  retro-cecal 
or  densely  adherent  high  in  the  right  iliac  fossa. 

For  other  cases  four  methods  of  entering  the  abdominal  cavity 
are  available:  the  muscle-splitting  operation  popularized  by 
McBurney;  an  incision  through  the  aponeurosis  just  outside  of 
and  parallel  to  the  right  rectus;  the  trap-door  incision  through 

the  right  rectus  fascia,  draw- 
ing the  muscle  medianward 
after  incising  the  anterior  layer 
of  the  rectus  sheath  and  incis- 
ing the  posterior  sheath  directly 
underneath  the  anterior  inci- 
sion; and  the  oblique  incision 
between  the  margin  of  the  rec- 
tus and  anterior-superior  iliac 
spine.  The  button-hole  inci- 
sion has  no  place  in  modern 
surgery  which  appreciates  that 
a  patient  who  submits  to  anaes- 
thesia and  operation  is  entitled 
to  an  exploration  of  neighboring  organs  and  the  reHef  of  any 
surgical  condition  present,  even  if  previously  undiagnosed. 

The  incision,  no  matter  which  one  is  chosen,  should  be  ade- 
quate or  capable  of  enlargement  without  undue  mutilation. 

In  early  first  attacks  of  acute  appendicitis  when  the  appendix 
is  positively  intra-peritoneal  the  muscle-splitting  incision  is 
satisfactory,  as  it  also  is  in  chronic  appendicitis  with  no  suspicion 
of  gall-bladder  infection.  It  cannot,  however,  be  satisfactorily 
enlarged  to  meet  emergencies  without  cutting  the  muscle  trans- 
versely at  some  point. 

The  trap-door  incision  is  suitable  for  any  case  which  will  not 
need  drainage  through  the  incision. 

The  incision  just  outside  of  and  parallel  to  the  rectus  meets 


Fig.  247. — Fouf  incisions  for  opera- 
tions upon  the  appendix. 


APPENDECTOMY 


545 


all  the  indications  at  all  times,  but  does  not  permit  of  as  satis- 
factory closure  as  the  first  two. 

The  oblique  incision  directly  through  all  the  muscles  gives 
rise  to  hernia  when  free  drainage  is  necessary,  but  occasionally 
it  must  be  used  in  order  to  adequately  expose  an  appendicular 
abscess  which  is  external  to  or  behind  the  caecum. 

Locating  the  Appendix. — In  chronic  appendicitis,  and  in  early 
acute  cases,  the  small  intestine  and  omentum  should  be  pushed 
toward  the  median  line  and  kept  there  by  a  sponge  if  they  tend 
to  protrude.  The  coil  of  intes- 
tine most  posteriorly  and  to 
the  right  is  always  the  caecum 
and  ascending  colon.  In  pick- 
ing this  up  its  anterior  longi- 
tudinal band  is  followed  to 
the  base  of  the  caecum,  thus 
exposing  the  ileo-cecal  junc- 
tion. No  matter  where  the 
tip  of  the  appendix  may  be, 
its  base  is  definitely  found  at 
the  inferior  end  of  the  anterior 
longitudinal    band,     and    the 

base  of  the  caecum  is  positively  ,  Fig.   248— Most  common  location  of 

•^           ,      "^  the  appendix  but,     no  matter  where  the 

reached  just  inferior  to  the  ileo-  tip  of  the  appendix,  its  base  is  definitely 

1  •         .•             rr-i      1      i     ^^A  found  at  the  inferior  end  of  the  anterior 

cecal  junction.     The  body  and  longitudinal  band." 
tip   of   the  appendix  may  lie 

anywhere  within  a  circle  whose  radius  is  the  length  of  the  ap- 
pendix, and  whose  center  is  the  appendico-cecal  junction,  but 
having  found  the  latter  the  appendix  can  always  be  traced, 
even  if  completely  buried  beneath  adhesions  or  behind  the 
caecum.  The  appendix  always  is  present  unless  it  has  been 
removed  by  a  previous  operation. 

In  very  early  acute  cases,  and  in  chronic  appendicitis,  the 
adhesions  about  the  appendix  are  separated  and  its  mesentery 
demonstrated,  the  appendix  being  drawn  from  the  abdominal 

35 


546      DISEASES   ASSOCIATED    WITH   GYNECOLOGIC   LESIONS 

cavity  and  completely  outside  the  incision  if  possible.  Occa- 
sionally the  organ  is  so  densely  bound  down  that  intestinal 
injury  is  to  be  feared  if  an  attempt  is  made  to  release  it  by  the 
separation  of  the  adhesions  which  surround  it.  In  such  cases 
the  cecal  junction  is  found,  the  peritoneum  over  the  base  of  the 


Fig.   249. — Appendectomy.     The  appendix  buried.     The  peritoneum  over  the 
appendix  is  split  longitudinally. 

appendix  split  longitudinally,  and  the  muscular  coat  separated 
from  the  peritoneal  by  blunt  dissection  around  its  entire  circum- 
ference. Slight  traction  on  the  exposed  portion,  while  blunt 
dissection  continues  toward  its  tip,  brings  out  the  entire  ap- 
pendix minus  its  peritoneal  coat.     In  this  event  no  mesenteric 


APPENDECTOMY 


547 


ligature  is  needed,  a  stitch  or  two  in  the  separated  peritoneal 
shell  controlling  the  bleeding. 

In  cases  of  acute  appendicitis  which  have  lasted  sufficiently 
long  to  provoke  many  adhesions,  or  in  which  perforation  and 
abscess  have  developed,   the  prehminary  walling  off  of  the 


Fig.  250. — Appendectomy.     The   appendix   buried.     "The   muscular   coat   is 
separated  from  the  peritoneal  by  blunt  dissection." 


abdominal  cavity  should  be  very  carefully  performed  before 
interfering  with  the  caecum  or  the  mass  of  adhesions  in  which  the 
appendix  is  buried.  Sometimes  one  will  find  the  anterior 
abdominal  wall  adherent  to  the  mass  beneath  the  incision,  in 
which  event  packing  can  be  dispensed  with,  but  any  opening  in 
the  wall  of  adhesions  should  be  carefully  plugged,  both  to  pre- 


548      DISEASES   ASSOCIATED    WITH   GYNECOLOGIC   LESIONS 

vent  leakage  of  pus  into  the  healthy  peritoneal  cavity  and  pro- 
trusion of  healthy  gut  into  the  infected  region.  If  there  are  no 
such  adhesions  the  abdominal  cavity  should  be  protected,  below, 
toward  the  median  line,  and  above,  by  a  sufficient  number  of 
sponges  to  prevent  contamination.  It  is  true  that  intra-abdom- 
inal pressure  will  usually  cause  all  pus  to  flow  outward,  but  the 


Fig.  251. — Appendectomy.     The    appendix    buried.     The    entire    appendix    is 
brought  out  minus  its  peritoneal  coat. 


collapse  of  a  large  abscess  cavity,  when  the  patient  is  anaesthe- 
tized and  the  muscles  relaxed,  might  allow  pus  to  escape  into  the 
general  peritoneal  cavity. 

The  mass  should  be  broken  into  with  the  finger,  which  seeks 
out  the  lines  of  least  resistance  between  the  coils  of  adherent 


APPENDECTOMY 


549 


gut,  and  it  often  happens  that  the  appendix  can  be  quickly  out- 
lined, especially  in  cases  which  have  lasted  but  three  or  four 
days.  If  it  cannot  thus  be  found,  the  anterior  cecal  band  should 
be  traced  to  its  base,  and  adhesions  gently  pushed  away  as  the 
finger  outlines  the  appendix,  until  it  can  be  demonstrated  as 


Fig.  252. — -Appendectomy.     Clamping  the  mesentery. 


before.  In  an  old  abscess  case  in  which  the  appendix  forms  an 
integral  part  of  the  median  wall,  and  in  old  retro-cecal  abscesses 
which  are  best  opened  extraperitoneally,  it  may  be  injudicious 
to  seek  the  appendix  at  all,  both  because  the  peritoneal  cavity 
will  be  badly  contaminated  and  because  absorption  from  these 


550      DISEASES   ASSOCIATED    WITH   GYNECOLOGIC    LESIONS 

surfaces  is  extremely  rapid,  but  these  cases  seem  to  grow  more 
rare  as  one's  experience  increases. 

Ligation  of  the  Mesentery  and  Treatment  of  the  Stump. — The 
mesentery  should  be  ligated  in  one  or  more  sections,  depending 
upon  its  leno:th  and  thickness.     Clamping  may  precede  the 


Fig.  253. — Appendectomy.     The  mesentery  severed. 

ligature  if  the  mesentery  is  readily  drawn  up,  but  with  a  short 
fat  mesentery,  or  one  friable  from  oedema,  it  is  safer  to  tie  in 
situ,  snipping  away  as  much  as  has  been  safely  ligated.  Very 
short  stumps,  and  loosely  placed  ligatures  and  sutures,  have  no 
place  in  the  removal  of  an  appendix  unless  one  wishes  to  reopen 
in  the  middle  of  the  night  to  stop  hemorrhage.     Care  is  neces- 


APPENDECTOMY 


551 


sary  in  ligating  the  mesentery  not  to  catch  the  wall  of  the  ileum, 
or  kink  the  ileum  at  its  junction  with  the  caecum. 

Before  the  appendix  is  amputated  the  intestine  and  abdom- 
inal incision  should  be  protected  with  sponges,  else  local  periton- 
itis with  subsequent  adhesions,  or  abscess  in  the  abdominal  wall, 
is  bound  to  follow  in  a  fair  proportion  of  cases. 


Fig.  254. — The  purse  string  suture  laid,  the  base  of  the  appendix  crushed, 
plain  catgut  ligature  in  position  to  tie  around  the  crushed  portion. 


A 


Many  methods  of  managing  the  stump  have  been  devised. 
Ligation  of  the  base,  amputation  of  the  appendix,  and 
cauterization  of  the  exposed  mucosa  being  the  simplest,  and 
this  may  be  practised  with  satisfaction  whenever  drainage  must 


552      DISEASES   ASSOCIATED    WITH   GYNiECOLOGIC   LESIONS 

be  employed.  According  to  some  good  authorities  the  same 
simple  treatment  is  perfectly  adequate  in  all  cases,  but  such 
treatment  of  exposed  infected  stumps  would  scarcely  be  con- 
sidered good  practice  in  intestinal  resection,  and  appendectomy 
is  but  a  miniature  resection.  Burying  the  exposed  stump  in  the 
raw  surface  of  the  mesentery  also  has  its  advocates.  On  the 
whole,  that  method  which  consists  of  crushing  the  base  with 


Fig.  255. — The  mesentery  ligated.     The  stump  crushed  and  tied  and  ready  for 

inversion. 

ha^mostats  to  force  the  mucosa  away  from  the  place  of  ligation, 
tying  a  fme  plain  catgut  ligature  in  the  groove  thus  formed,  am- 
putating the  appendix  beyond  the  ligature,  cauterizing  the  little 
cup  in  the  stump,  and  then  invaginating  the  stump  into  the 
cecal  wall  with  a  purse  string  suture,  appeals  to  one's  sense  of 
surgical  neatness  and  finish,  and  its  results  bear  out  this  feeling. 
The  purse  string  suture  should  be  laid  before  crushing  the 


APPENDECTOMY 


553 


appendix,  and  additional  finish  and  security  are  accomplished 
by  a  running  suture  of  fine  catgut  which  whips  over  ana  buries 
the  purse  string  and  extends  over  the  entire  cut  surface  of  the 
mesentery.  This  last  suture  many  times  can  be  so  applied  as  to 
leave  no  raw  surface  whatever  in  the  abdomen. 

The  caecum  is  now  sponged  off  with  warm  saline  and  replaced, 
if  it  has  been  drawn  out.     If  a  beginning  abscess  were  present. 


Fig.   256. — Appendectom3^     A  suture  of  fine  catgut  buries  the  purse  string  and 
extends  over  the  cut  edges  of  the  mesentery, 

its  cavity  is  carefully  sponged  and  dried  and  a  last  look  is  taken 
to  make  sure  that  no  hemorrhage  persists.  In  chronic  cases,  and 
in  acute  cases  with  no  infection  outside  the  appendix,  the 
abdomen  is  closed  in  layers.  In  the  presence  of  pus  drainage 
does  no  harm  and  may  save  life.  The  extent  and  character  of 
the  drainage  depends  upon  the  conditions  present  and  deserves 
special  consideration. 

If  a  peri-appendicular  abscess  is  strictly  localized  and  well 


554      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC   LESIONS 

walled  in  on  all  sides,  nothing  more  than  a  fair-sized  soft  rubber 
drain  is  necessary. 

If  there  is  an  abscess  whose  walls  are  not  adherent  to  the 
anterior  abdominal  wall,  so  that  escaping  pus  must  traverse  some 
portion  of  the  free  abdominal  cavity,  it  is  judicious  to  fluff 
into  it  a  considerable  quantity  of  gauze  in  addition  to  the  tube, 
not  to  serve  as  a  drain  but  to  keep  healthy  intestine  out  of  the 
infected  territory  and  to  stimulate  the  early  formation  of 
adhesions  about  the  gauze,  and  so  protect  the  peritoneal  cavity. 

If  the  abscess  is  very  large  and  the  infection  is  virulent  as 
revealed  by  the  patient's  condition,  it  is  occasionally  judicious 
to  insert  no  sutures,  merely  opening  and  draining  and  keeping 
healthy  intestine  back  by  a  light  gauze  cofferdam.     ~ 

At  times  there  is  no  local  abscess,  but  the  appendix  is  perfo- 
rated and  the  peritoneum  about  it  very  much  reddened  and 
scalded  in  appearance,  while  coils  of  intestine  whose  peritoneal 
coat  is  not  involved  are  in  close  proximity.  Under  such  cir- 
cumstances the  light  cofferdam  separating  healthy  from  infected 
territory  is  eminently  judicious. 

Many  times  one  will  find  only  an  area  of  local  infection  about 
a  perforated  or  gangrenous  appendix,  while  the  preceding 
severity  of  the  symptoms  and  the  tenderness  and  rigidity  over 
the  anterior  wall  led  him  to  suspect  a  diffuse  peritonitis.  In 
such  a  case,  if  a  clean  finger  or  stiff  drainage  tube  is  pushed 
through  the  lower  end  of  the  incision  into  the  pelvic  cavity,  one 
is  usually  rewarded  by  a  gush  of  pus  and  sero-purulent  fluid. 
A  drain  should  then  be  placed  to  the  bottom  of  the  pelvic  cavity, 
which  not  only  will  drain  what  would  otherwise  become  a 
residual  abscess,  but  may  abort  a  threatened  peritonitis.  Such 
a  drain  may  be  brought  out  of  the  lower  angle  of  the  incision,  or 
through  a  stab  wound  low  in  the  median  line,  or  into  the  vagina 
through  the  cul-de-sac.  The  first  and  last  are  better  than  the 
median  stab  wound,  which  passes  between  free  intestinal  coils 
throughout  its  entire  length  and  sometimes  gives  rise  to  bands 
of  adhesions  and  subsequent  obstruction.     When  possible,  it 


VISCERAL   PTOSIS  555 

is  best  to  have  abdominal  drains  in  contact  with  parietal 
peritoneum. 

Much  harm  is  done  by  the  early  removal  of  gauze  drains  and 
packs.  If  these  are  made  of  iodoform  gauze  they  do  not  be- 
come offensive  for  several  days  and  may  be  retained  until 
thoroughly  loosened.  Early  withdrawal  of  gauze  which  is  in 
contact  with  peritoneum  breaks  up  protective  adhesions,  pro- 
duces considerable  bleeding,  and  may  drag  intestine  into  the 
depths  of  the  incision  where  it  becomes  adherent  and  forms  the 
starting  point  for  a  post-operative  hernia.  Tube  drains  should 
be  allowed  to  remain  until  the  cavity  in  which  they  are  placed 
has  collapsed,  and  the  external  orifice  is  as  large  as  the  bottom 
of  the  drainage  tract. 

The  foregoing  discussion  of  drainage  following  operation 
for  acute  appendicitis  may  seem  uncalled  for  at  a  time  when  the 
disposition  among  surgeons  has  become  so  pronounced  in  favor 
of  removing  the  appendix  and  allowing  nature  to  care  for  the 
remaining  infection  once  its  cause  is  removed,  but  the  fact 
that  infection  has  spread  beyond  its  original  site  is  evidence 
that  nature  is  not  all-sufficient,  and  the  time  will  soon  come 
when  the  tendency  to  trust  to  nature  will  be  overthrown  in 
favor  of  the  plan  of  trusting  only  so  much  to  nature  as  can- 
not'quickly  and  safely  be  removed. 

VISCERAL   PTOSIS 

Ptosis  of  some  or  all  of  the  abdominal  viscera  is  often  found 
in  association  with  gynaecological  disease,  and  the  question 
then  arises  as  to  whether  one  or  the  other  is  the  cause  of  the 
symptoms  of  which  the  patient  complains,  and  whether  inter- 
ference with  the  ptosed  viscus  is  necessary. 

The  last  word  cannot  be  said  concerning  visceral  ptosis,  but 
in  a  general  way  the  following  propositions  are  true : 

I.  Displacement  of  a  viscus  in  such  manner  as  to  interfere 
with  its  normal  functionating,  causes  discomfort. 


556      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC   LESIONS 

2,  Displacement  in  such  manner  as  to  interfere  with  the 
normal  blood  supply,  provokes  symptoms. 

3.  Traction  upon  the  normal  attachments  produces  disturb- 
ances in  some  patients  and  none  whatever  in  others. 

As  an  example  of  the  first  proposition  may  be  cited  a  pro- 
lapsed but  otherwise  normal  stomach,  the  pyloric  end  of  which 
is  so  fixed  that  the  stomach  fails  to  empty  itself  as  it  should. 

As  an  example  of  the  first  and  second,  a  floating  kidney  may 
become  so  rotated  as  to  interfere  with  the  venous  return  through 
the  renal  vein,  and  simultaneously  the  ureter  may  be  so  bent 
upon  itself  as  to  cause  acute  hydronephrosis  and  a  true  Dietl's 
crisis. 

Illustrating  the  third,  we  see  patients  whose  transverse  colons 
together  with  practically  all  the  small  intestine,  are  contained 
in  the  pelvic  cavity,  some  of  whom  feel  better  when  lying  down 
with  the  hips  elevated,  and  some  of  whom  feel  so  well  that  it  is 
impossible  for  them  to  feel  better.  In  these  patients  there 
again  comes  into  view  the  fact  that  some  nervous  systems 
are  hypersensitive  and  in  such  a  state  of  unstable  equilibrium, 
as  concerns  sensations,  that  minor  disturbances  sufiicc  to 
produce  major  results. 

There  is  no  doubt  that  a  prolapsed  transverse  colon  is  some- 
times the  cause  of  trouble  and  that  a  pelvic  caecum  sometimes 
gives  rise  to  pain,  but  this  is  far  more  Hkely  to  follow  if  they 
are  anchored  in  their  position  by  adhesions.  Peristalsis  which 
normally  suffices  to  push  a  fecal  mass  directly  up  the  caecum 
ought  to  be  sufficient  to  force  it  through  a  prolapsed  transverse 
colon  if  the  latter  is  unhampered  and  unkinked  by  adhesions. 
Likewise  a  prolapsed  stomach  should  make  no  trouble  if  it  is 
all  prolapsed  so  that  it  empties  within  the  normal  time,  but 
just  what  effect  is  produced  by  constant  traction  upon  the 
gastro-hepatic  omentum  is  uncertain. 

Ptosis  so  marked  that  the  viscera  descend  well  into  the  pelvic 
cavity  is  a  cause  of  backache,  but  whether  this  is  from  mesen- 
teric traction,  or  from  the  static  effect  of  constant  tension  of  the 


I 


VISCERAL   PTOSIS  557 

lumbar  muscles  in  an  unconscious  effort  at  preserving  the 
bodily  equilibrium,  is  unknown.  Pregnant  patients  and  those 
with  abdominal  tumors  often  suffer  from  a  similar  backache 
which  is  probably  static. 

Ptosis  of  the  stomach  and  transverse  colon,  to  such  an  ex- 
tent or  of  such  form  that  marked  symptoms  are  produced, 
should  be  dealt  with  surgically  if  bandages  fail  to  overcome 
the  symptoms. 

Pelvic  adhesions  which  hold  either  the  stomach  or  colon  out 
of  position  should  be  released  if  the  abdomen  is  opened  for 
any  purpose. 

For  the  symptom- producing,  prolapsed  stomach  and  colon 
without  adhesions,  Rovsing  has  described  the  most  satisfactory 
operation,  and  one  which  withal  accomplishes  its  object. 

It  is  obvious  that  a  kidney  whose  displacement  is  of  such 
a  character  as  to  produce  repeated  attacks  of  hydronephrosis 
needs  surgical  attention,  either  nephropexy  or  nephrectomy. 
The  ordinary  movable  kidney  scarcely  needs  fixation  unless  the 
patient  has  other  lesions  which  demand  anaesthesia  and  surgical 
intervention.  The  author  is  constantly  leaning  toward  con- 
servatism in  advising  operation  for  movable  kidney,  per  se,  be- 
cause the  results  of  nephropexy  are  so  often  unsatisfactory; 
and  on  the  contrary,  when  interference  is  positively  necessary, 
he  is  becoming  more  radical  in  advising  removal  of  the  offend- 
ing organ,  providing  the  other  kidney  is  not  only  present  but 
functionating  satisfactorily. 

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ASCHOFF. — Pathogenese  und  Atiologie  der    Appendicitis.     Ergeb.  der  Inner 

Med.  und  Kinderheil,  191 2,  ix,  i. 
BOIT   UND    HEYDE. — Experimentelle    Untersuchungen    zur    Aetiologie    der 

Wurmfortsatzentziindung.     Beitrage  zur  klin.  Chirurg.,  191 2,  Ixxix,  271. 
HEYDE.— Bakteriologischc  und  experimentelle  Untersuchungen  zur  Aetiologie 

der     Wurmfortsatzentziindung     (mit     besonderer     Beriicksichtigung     der 

anaeroben  Bakterien.     Beitrage  zur  klin.  Chirurg.,  1911,  Ixxvi,  i. 


REFERENCES      "  559 

ALBRECHT. — Ueber    angeborene    Lageanomalien    des    Wurmfortsatzes    und 
angeborene   Disposition  fur  Appendizitis.     Wien.  klin.  Woch.,  1909,  xxii, 

1359- 
BOLOGNESE. — Die    Appendizitis,    Klinischer    und    histologischer    Beitrag. 

Arch.  f.  Path.  Anal.,  1912,  ccviii,  21. 
COLLEY. — Beitrage  zur  Klarung  der   Frage  von  der  Erblichkeit  der  Entz- 

iindung  des  Blinddarmhanges.  Arch.  f.  klin.  Chirurg.,  1914,  ciii,  177. 
FOWLER. — Foreign  Body  Appendicitis.  Annals,  of  Surg.,  1912,  Ivi,  427. 
CECIL  AND  BULKLEY.— On  the  Lesions  Produced  in  the  Appendix  by  Oxyuris 

Vermicularis  and  Tricocephalus  Trichiura.     /.  Exp.  Med.,  1912,  xv,  225. 
SCHULTZE. — Die  heutige  Bewertung  der  Blutunterschungen  bei  der  Appen- 
dicitis  b.z.w.   freien  fortschreitenden  appendicitischen   Peritonitis.     Mitt. 

a.d.  Grenz.  der  Med.  u.  Chir.,  1913,  xxvi,  61. 
KOHL. — Weitere  Beobachtungen  iiber  Wert  und  Bedentung  der  Leukocytose 

und  des  neutrophilen  Blutbildes  bei  der  Appendicitis.     Mitt.  a.d.  Grenz. 

der  Med.  u.  Chir.,  191 1,  xxii,  542. 
SCHMIDT. — Ueber  den  Wert  der  Leucocytenzahlung  bei  Appendicitis.     Mitt. 

a.d.  Grenz.  d.  Med.  w.  Chir.,  191 1,  xxiii,  865. 
FRISCH. — Ueber    Hamaturie    bei    Appendizitis.     Wien.    klin.    Woch.,    191 2, 

XXV,  30. 
RICHARDSON.— The  Error  of  Overlooking  Ureteral  or  Renal  Stone  under  the 

Diagnosis  of  Appendicitis.     Annals  of  Surg.,  1912,  Iv,  264. 
HOFFMAN.^ — Erfahrungen    und    Resultate    unserer   Perityphilitisbehandlung 

bei  4000  operierten  Fallen.  Beitrage  zur  klin.  Chir.,  191 2,  Ixxix,  305. 
SONNENBURG,  E.— Die  Appendicitis    einst  und    jetzt.     Berl.  klin.   Woch., 

1913,  1,  2313. 

SASSE. — Zur  Behandlung  die  diffusen  eitrigen  Wurmforsatzperitonitis.     Arch. 

f.  klin.  Chirurg.,  1914,  ciii,  780. 
MORRIS,  ROBERT.— Normal  Involution  of  Appendix.     Brooklyn  M.  J.,  1904, 

xviii,  44. 
DELFINO. — Hypertrophische  Blinddarmtuberkulose.     Arch.  f.  klin.  Chirurg., 

1 9 14,  ciii,  845. 

SOLIERE. — Ueber  den  epigastrischen  Schmerz  bei  Appendicitis.     Mitt.  a.d. 

Grenz.  d.  Med.  u.  Chir.,  19 13,  xxv,  240. 
MUELLER. — Ueber  die  Beziehungen  der  Appendicitis  Chronica  zu  den  weib- 

lichen  Beckenorganen.     Muen.  med.  Woch.,  191 2,  lix,  2856. 
GEORGE  AND  GERBEE.— The  Value  of  the  Roentgen  Method  in  the  Study 

of  Chronic  Appendicitis,  etc.     Surg.,  Gyn.  &°  Obst.,  1913,  xviii,  418. 
HERTZ. — Bastedo's  Sign;  A  New  Symptom  of  Chronic  Appendicitis.    Froc. 

Roy.  SoG.  of  M.,  1913;  Clinical  Sec,  vi,  185. 
TYRODE.— Relation  of  Chronic  Appendicitis  to  Colitis.     Bost.  M.  b-  S.  /., 

1912,  clxvi,  I. 
PILCHER. — Surgical  Aspects  of  Membranous    Pericolitis.     Annals  of  Surg., 

1912,  Iv,  I. 
AARON. — A  Sign  Indicative  of  Chronic  Appendicitis.     J.  A.  M.  A.,  Ix,  350. 


560      DISEASES   ASSOCIATED   WITH   GYNECOLOGIC  LESIONS 

SYMS,  P. — Operative  and  Post-operative  Treatment  of  Appendicitis.     N.  York 

M.  J.,  1914,  xcix,  761. 
JOHNSON,   A.  B. — Technique  of  the  Operative  Treatment  of  Appendicitis. 

Annals  of  Surg.,  191 1,  liii,  525. 
MacLAREN,  A. — The   Proper  Treatment  of  Intraperitoneal  Abscess  in  the 

Lower  Abdomen.     /.  A.  M.  A.,  liv,  2105. 
KNOTT,     VANBUREN.— Treatment     of    Localized     Appendicular     Abscess. 

/.  A.  M.  A.,  1911,  Ivii,  525. 
ANDREW,   J.   G. — Operation  for  Acute   Appendicitis.     Primary   Closure   of 

Abdominal  Wound.     Glasgow  M.  /.,  1913,  Ixxx,  161. 
GOLDTHWAIT,  J.  E.— The  Real  Significance  of  Visceroptosis.    Penn.  M.  /., 

1913-14,  xvii,  523. 
GREEN.— The  R61e  of  Ptosis  in  Gynaecology.     Bost.  M.  &'  S.  J.,  1913,  clxviii, 

12. 
REYNOLDS,  EDWARD.— The  Etiology  of  the  Ptoses  and  Their  Relation  to 

Neurasthenia.     Trans.  Am.  Surg.  Assn.,  1910,  xxviii,  473. 
KELLY,    HOWARD   A. — Movable    Kidney   and   Neurasthenia.     Trans.    Am. 

Surg.  Assn.,  1910,  xxviii,  513. 
REED,  C.  A.  L. — The  Relation  of  Gastrocolic  Displacements  to  Certain  Intra- 

pelvic  Conditions  in  Women.     Trans.  Am.  Assn.  Obst.  b°  Gyn.,  1911,  xxiv, 

292. 
SMITH,  R.  R. — A  Description  of  the  Enteroptotic  Woman.     Surg.,  Gyn.  6* 

Ohsl.,  1913,  xvii,  71. 
SUCKLING,  C.  W.— Neurasthenia  and  Movable  Kidney.     The  Practitioner, 

1911,  i,  96. 
LESLIE. — Visceroptosis  and  Its  Treatment.     Clinical  Journ.,  191 2,  xl,  49. 
LANE,  SIR  W.  A. — Chronic  Intestinal  Stasis.     Med.  Press.,  1913,  cxlvii,  522; 

Ibid.,  1914,  cxlviii,  116. 
RANSOHOFF. — Gastroenteroptosis.     Surg.,  Gyn.  &"  Obst.,  191 2,  xv,  21. 
MARTIN. — Gymnastics  and  Other  Mechanical  Means  in  the  Treatment  of 

Visceral  Ptosis  and  Its  Complications.     Tr.  Am.  Gyn.  Soc,  191 2,  xxxvii, 

133;  Surg.,  Gyn.  b°  Obst.,  1912,  xv,  150. 
BEYEA. — The    Surgical    Treatment  of   Gostroptosis.    Penn.  M.  J.,  1913-14, 

xvii,  527. 
KOCHER,  TH. — Zur  operativen  Behandlung  der  Wanderniere.     Corres.  Blalt. 

}.  Schw.  Aerzte.,  1913,  xliii,  545. 
ROVSING. — Gastrocoloptosis.     /.  A.  M.  A.,  191 2,  lix,  334. 


CHAPTER  XIX 
GYNECOLOGIC  SURGERY 

In  appropriate  places  and  in  connection  with  various  opera- 
tive procedures,  mention  has  been  made  of  such  preparation 
for  operation,  methods  of  securing  asepsis,  suture  material, 
etc.,  as  seemed  necessary  for  the  particular  operation.  The 
present  chapter  takes  up  a  more  systematic  discussion  of  the 
principles  and  details  of  gynaecologic  surgery. 

General  surgical  technique  is  the  same  no  matter  what  por- 
tion of  the  body  is  invaded,  but  the  details  are  somewhat 
modified  by  the  anatomy  and  physiology  of  the  locality. 

Pre-operative  Treatment.- — Excepting  in  cases  of  dire  ex- 
tremity, such  as  ruptured  ectopic  pregnancy,  torsion  of  the 
pedicle  of  an  ovarian  tumor,  and  intestinal  obstruction,  there 
is  abundant  time  in  gynaecology  for  pre-operative  observation 
and  treatment.  In  considering  pre-operative  treatment  it 
should  be  borne  in  mind  that  gynaecologic  surgery  may  be  di- 
vided into  two  classes:  first,  the  surgery  of  necessity;  second, 
the  surgery  of  election.  To  the  former  belong  those  operations 
which  are  needed  in  order  to  save  or  prolong  life;  to  the  latter 
those  which  are  designed  to  relieve  discomfort.  An  operation 
may  be  perfectly  justified  in  the  first  class  under  circumstances 
which  would  prohibit  operation  in  the  second.  Treatment 
designed  to  place  the  patient  in  the  best  possible  condition  is 
often  judicious  for  one  who  must  have  an  ovarian  cyst  removed 
or  a  fibromatous  uterus  extirpated,  even  though  she  has  diabetes, 
nephritis,  or  a  bad  heart  lesion,  while  the  propriety  of  doing  a 
trachelorrhaphy,  perineorrhaphy,  or  round  ligament  operation 
on  a  patient  having  such  vascular  or  systemic  diseases  would  be 
36  561 


562  GYNiECOLOGIC    SURGERY 

very  questionable.  Such  pre-operative  treatment  is  distinctly 
medical  and  must  be  undertaken  on  general  medical  principles. 

Under  ordinary  circumstances  the  pre-operative  treatment  is 
limited  to  such  measures  as  will  make  operation  safe  and  rapid, 
and  minimize  discomfort. 

It  is  wiser  to  have  the  patient  in  the  hospital  a  day  or  two 
before  operation.  By  so  doing  she  becomes  familiar  with  her 
surroundings,  and  the  emotional  excitement  incidental  to 
leaving  home  will  have  subsided.  The  nervous  strain  to  which 
most  women  are  subjected  by  forcing  them  suddenly  into 
unfamiliar  surroundings  is  not  sufficiently  appreciated. 

Diet. — The  diet,  immediately  preceding  operation  of  any 
kind,  should  be  restricted  because  digestion  is  likely  to  be  dis- 
turbed through  anxiety,  and  emotional  loss  of  appetite  is  a 
physiological  safeguard.  If  an  abdominal  operation  is  con- 
templated, the  simplest  forms  of  food  and  those  which  leave 
but  little  residue  should  be  selected,  and  the  ordinary  hospital 
Hquid  diet,  without  milk,  is  ordered.  Milk  should  not  be 
taken  because  in  many  individuals  flatulence  is  an  almost 
regular  sequence  of  its  ingestion,  and  a  flaccid  undistended 
intestine  is  much  to  be  desired.  If  only  a  vaginal  opera- 
tion is  to  be  done  the  dietary  restrictions  need  not  be  so  severe, 
as  intestinal  distension  does  not  interfere  with  the  operative 
manipulations,  but  the  patient  is  more  comfortable,  and  post- 
operative elevation  of  temperature  is  less  if  the  stomach  and 
bowels  are  empty. 

An  abundance  of  water  should  be  taken  on  the  day  and 
night  preceding  operation,  as  post-operative  thirst  is  thereby 
minimized  and  the  urinary  output  increased.  Both  food  and 
water  should  be  discontinued  from  three  to  Ave  hours  before 
the  time  set  for  operation  so  that  the  stomach  may  be  empty 
when  the  anaesthetic  is  administered. 

Catharsis. — Pre-operative  catharsis  aims  to  produce  the 
same  effect  as  restricted  diet,  viz.,  a  flaccid  empty  bowel.  A 
half  ounce  of  castor  oil  taken  early  on  the  night  preceding  opera- 


PRE-OPERATIVE    TREATMENT  563 

tion  usually  acts  in  a  few  hours,  and  if  an  enema  is  given  at 
least  four  hours  before  operation  the  bowel  is  likely  to  be  found 
in  a  thoroughly  satisfactory  condition.  The  taste  of  oil  can 
be  disguised  by  floating  it  on  orange  juice  or  making  an  orange- 
ade "sandwich,"  and  it  is  not  nauseating  when  the  taste  is 
well  covered.  Drastic  purges  not  only  weaken  the  patient, 
but  they  also  fill  the  bowel  with  gas  and  intestinal  secretions, 
and  it  is  rare  indeed  that  a  single  dose  of  oil  is  not  satisfactory 
if  followed  by  one  or  two  low  enemas.  If  vaginal  work  is 
contemplated  care  must  be  taken  that  the  enema  is  given 
several  hours  before  operation  and  that  it  is  entirely  expelled, 
else  the  operative  field  may  be  soiled  by  its  evacuation  after  the 
patient  is  anaesthetized.  In  very  nervous  patients  it  is  some- 
times necessary  to  insert  the  rectal  tube  in  order  to  be  assured 
that  the  lower  bowel  is  empty,  and  the  nurse  should  do  this 
if  she  finds  that  less  fluid  has  been  expelled  than  was  introduced. 
Medication. — Very  apprehensive  patients  do  better  if  they 
are  given  a  sedative  the  night  preceding  operation,  wholly  aside 
from  its  administration  as  an  aid  to  anaesthesia.  A  full  dose 
of  sodium  bromide  is  sufficient  for  mere  "nervousness/'  but  the 
extreme  apprehesion  which  may  precede  a  dangerous  ab- 
dominal operation  should  be  met  by  a  small  dose  of  opium  in 
some  form.  The  difference  between  a  patient  who  literally 
is  half  frightened  to  death,  and  one  who  is  composed,  sometimes 
measures  the  actual  difference  between  death  and  recovery. 

ASEPSIS    AND    ANTISEPSIS 

Volumes  have  been  written  on  this  subject  without  exhausting 
it,  and  its  evolution  from  the  crude  methods  of  Lister  to  the 
simple  efficient  methods  of  the  present  time  makes  an  interest- 
ing study,  but  the  whole  practice  of  asepsis  is  based  upon  a 
few  fundamental  facts. 

Surgical  infection  is  dependent  upon  the  introduction  of 
pathogenic  bacteria  into  a  wound  in  sufficient  numbers,  and  of 


5O4  GYNECOLOGIC    SURGERY 

a  requisite  degree  of  virulence,  to  overcome  the  resistance  of 
the  tissues  of  that  particular  individual. 

Infection  does  not  occur  if  there  are  no  bacteria  whatever 
in  the  wound,  a  condition  which  is  never  fulfilled  clinically,  or 
if  their  numbers  are  so  small  and  their  virulence  so  slight  that 
the  natural  immunizing  powers  are  sufficient  to  neutralize  their 
effect  or  destroy  them  altogether. 

Clinical  asepsis  is  obtained  by  minimizing  the  number  of 
bacteria  of  any  kind  which  gain  access  to  a  wound,  and  entirely 
preventing  the  entrance  of  virulent  organisms,  plus  such 
methods  of  handling  the  tissues  as  shall  best  preserve  their 
power  of  resistance.  Bacterial  contamination  is  the  well- 
understood  factor  of  the  problem;  no  bacteria,  no  infection. 
Resistance  of  the  tissues  is  less  perfectly  understood,  but  its 
influence  is  certainly  greater  than  is  generally  appreciated.- 
The  great  majority  of  patients  show  so  much  resistance  to 
infection  that  sloppy  and  even  careless  aseptic  technique 
usually  succeeds,  but  universally  good  results  can  be  obtained 
only  by  the  most  painstaking  attention,  both  to  aseptic  details 
and  the  preservation  of  the  vitality  of  the  tissues. 

Preparation  of  the  Operative  Pield. — It  is  fortunate  that 
nature  in  every  instance  provides  this  resistance  to,  or  im- 
munity from,  infection,  as  complete  sterility  of  any  operative 
field  is  impossible,  and  heroic  efforts  to  provide  an  absolutely 
aseptic  field  are  more  likely  to  damage  nature's  protective 
mechanism  than  to  secure  the  desired  sterility.  The  last  word 
has  not  been  said  on  this  subject,  but  the  following  methods 
have  been  carried  out  by  the  author  with  a  minimum  of  trouble, 
and  in  a  recent  series  of  500  operations  not  a  single  serious  in- 
fection arose,  and  no  infection  of  any  kind  took  place  unless 
the  wound  had  been  soiled  by  infectious  material  from  the 
interior  of  the  abdomen. 

The  day  preceding  operation  the  patient  is  given  a  sponge, 
not  a  tub,  bath  and  the  vulva  is  shaven.  If  the  operation  is 
to  be  limited  to  the  vagina  a  douche  of  sterile  soap  suds  is  given, 


ASEPSIS   AND    ANTISEPSIS  565 

followed  at  once  by  a  lysol  or  creolin  douche  in  the  strength 
of  y^i  to  I  per  cent.  No  especial  emphasis  is  laid  upon  the 
germicidal  power  of  such  a  douche — it  is  the  mechanical  cleans- 
ing which  is  important — but  as  the  patient  remains  in  bed  and 
a  small  quantity  of  solution  is  retained  in  the  vagina  there 
undoubtedly  is  some  inhibiting  power  in  the  douche  itself.  The 
douche  is  repeated  on  the  morning  of  the  operation. 

After  the  induction  of  anaesthesia,  the  patient  is  placed 
in  the  lithotomy  position  and  a  sterile  gloved  nurse  scrubs  the 
vulva,  inside  of  the  thighs,  and  buttocks  with  soap  and  water, 
using  gauze  instead  of  a  brush  for  this  purpose.  Care  is  taken 
that  the  anus  is  scrubbed  last  of  all,  no  sponge  that  has  come 
in  contact  with  the  anus  being  used  elsewhere. 

After  the  external  parts  are  thoroughly  cleansed  the  vagina 
is  scrubbed  with  soap  and  water,  using  sponges  rather  than  a 
brush,  and  the  entire  field  'both  internal  and  external"  is 
thoroughly  douched  with  sterile  water  poured  from  a  pitcher. 
The  preceding  is  unquestionably  the  important  feature  of  the 
preliminary  technique,  but  out  of  deference  to  general  surgical 
opinion  the  parts  are  again  washed  with  a  i  to  3000  mercuric 
chloride  solution,  the  latter  being  douched  away  with  sterile 
water. 

Great  stress  is  laid  upon  the  thorough  but  gentle  performance 
of  the  mechanical  cleansing,  so  that  cleanliness  is  assured  with- 
out abrasion  of  the  skin  or  mucous  membrane. 

If  an  abdominal  operation  is  contemplated,  the  bath  is  given 
as  before  and  the  abdomen  shaved.  The  nurse  carrying  out 
the  preparation  then  prepares  herself  as  for  an  operation,  and 
proceeds  to  scrub  the  abdomen  with  soap  and  sterile  gauze. 
The  soap  is  removed  with  sterile  water,  the  abdomen 
scrubbed  with  alcohol  which  is  not  removed,  and  a  sterile 
dry  dressing  applied  to  remain  until  the  patient  is  on  the  table. 
Here  one  of  two  methods  is  used.  Either  A,  the  abdomen  is 
again  scrubbed  with  soap  and  sterile  water,  next  with  alcohol, 
next  with  Harrington's  solution,  which  is  left  for  one  minute 


566  GYNECOLOGIC    SURGERY 

and  then  washed  off  with  alcohol,  after  which  the  abdomen  is 
covered  with  a  sterile  towel;  or  B,  the  abdomen,  which  has  not 
been  touched  with  water  since  the  preceding  evening,  is  painted 
once  with  tr.  iodine  of  the  regular  pharmacopeal  strength  and 
left  uncovered  until  throughly  dry. 

IVIethod  A  gives  perfect  results,  but  it  wets  the  patient  and 
her  clothing  which  is  a  decided  disadvantage. 

Method  B  also  gives  perfect  results  but  occasionally  produces 
severe  skin  irritation.  No  attempt  has  been  made  by  labo- 
ratory tests  to  establish  the  relative  sterility  secured  by  the 
two  methods,  as  the  laboratory  can  establish  the  presence  or 
absence  of  bacteria  only,  the  effect  upon  the  resistance  of  the 
tissues  not  being  demonstrable. 

The  fact  that  stitch  openings  in  the  skin  readily  become 
infected  when  catgut  is  used  for  superficial  sutures  led  to  a 
clinical  test,  skin  sutures  of  chromic  catgut  being  used  in  a 
large  number  of  cases  with  the  result  that  less  redness  showed 
about  them  after  method  B  than  after  method  A. 

It  is  noticeable,  even  when  the  iodine  is  given  time  to  dry 
thoroughly,  that  after  the  operation  is  completed  the  skin  has 
resumed  its  original  color,  the  iodine  having  disappeared. 
This  means  that  sponges  crowded  into  the  abdomen  and 
intestine  which  protrudes,  have  wiped  the  iodine  from  the 
skin,  and  a  certain  portion  of  it  must  have  been  carried  into 
the  abdominal  cavity.  It  is  desirable  to  prevent  this  by  the 
attention  to  the  drapes  which  is  mentioned  later. 

Hand  Disinfection. — Those  things  which  come  into  contact 
with  a  deliberately  inflicted  operative  wound  are  the  air, 
sponges,  instruments,  suture  material,  towels  and  sheets,  water 
or  solution,  and  the  hands  of  the  operator  and  his  assistants. 
Experience  has  shown  that  the  first  can  be  ignored  providing 
it  is  not  grossly  contaminated  by  dust;  all  else  excepting  the 
hands  can  be  sterilized  so  absolutely  as  to  be  germ  free.  The 
sterility  of  the  hands  is  always  relative.  The  hands  are  there- 
fore covered  with  rubber  gloves  which  are  as  readily  sterilizable 


ASEPSIS   AND   ANTISEPSIS  567 

as  the  other  material  coming  into  contact  with  the  wound,  but 
which  are  of  so  dehcate  a  character  as  to  be  easily  pricked  or 
torn.  For  the  latter  reason  hand  disinfection  must  be  as 
scrupulously  practised  when  gloves  are  worn  as  when  they  are 
not.  Assistants  and  nurses  who  dress  infected  wounds  should 
be  banished  from  the  operating  room,  as  the  complete  removal 
of  bacteria  from  the  hands  is  impossible  of  accomplishment  by 
any  method  which  permits  of  its  daily  use  without  destroying 
the  integrity  of  the  skin. 

The  first  and  prime  feature  of  hand  sterihty  is  the  avoidance 
of  hand  infection.  Any  and  all  infected  wounds  which  must 
be  dressed,  examined,  or  otherwise  handled,  should,  both  liter- 
ally and  figuratively,  be  handled  with  gloves.  All  dressings 
should  be  handled  with  instruments,  never  with  the  fingers; 
rectal  and  other  dirty  examinations  should  be  made  only  with 
gloved  hands.  In  this  way  and  this  way  only  can  contamina- 
tion of  the  hands  by  virulent  organisms  be  prevented.  Organ- 
isms not  virulent  can  be  so  reduced  in  numbers  by  ordinary 
methods  that  the  hands  are  relatively,  though  not  absolutely, 
sterile. 

Scrubbing  with  soap  and  sterile  hot  water  is  the  measure  of 
most  importance  in  the  technique  of  hand  sterihzation,  and 
this  scrubbing  should  be  continued  until  the  hands  are  clean. 

Cleansing  the  space  under  the  nails,  if  done  at  all,  should  be 
performed  before  scrubbing  is  begun,  not  afterward.  If  the 
nails  are  kept  short  and  a  stiff  brush  is  used  for  scrubbing  the 
preliminary  scraping  of  the  nails  is  not  needed,  and  it  is  of 
doubtful  propriety  in  any  event  as  it  keeps  the  nails  rough 
and  more  liable  to  accumulate  dirt. 

A  routine  time  for  washing  the  hands  is  ridiculous  since  one 
man  will  brush  twice  as  hard  and  twice  as  fast  as  another. 
The  scrubbing  should  begin  by  soaping  the  hands  well,  rubbing 
in  the  soap  until  a  good  lather  is  formed,  and  then  going 
briskly  over  each  finger  separately  and  on  all  sides,  giving  par- 
ticular attention  to  the  end  and  palmar  surface.     The  lather 


568  GYNiECOLOGIC    SURGERY 

should  be  washed  away  with  hot  water  and  the  process  re- 
peated time  and  again  until  the  hands  are  thoroughly  clean. 
For  one  who  brushes  briskly  15  minutes  is  sufficiently  long,  but 
a  lazy  or  indifferent  assistant  should  be  kept  at  his  task  for 
20  or  30  minutes.  Running  water  should  be  used  unless  the 
wash  bowls  are  above  suspicion,  a  condition  which  is  rare  even 
in  well-conducted  hospitals.  After  removing  the  soap  with 
sterile  water  various  methods  of  chemical  sterilization  are 
practised,  the  defect  in  each  of  them  being  the  fact  that  chemical 
sterilization  by  any  agent  which  will  not  destroy  the  skin  re- 
quires immersion  in  the  solution  for  many  minutes.  The  per- 
functory dipping  of  the  hands  in  mercuric  chloride  solution  for 
a  few  seconds  steriHzes  nothing  but  the  operator's  conscience. 
After  trying  many  methods,  including  staining  the  hands  and 
forearms  with  strong  permanganate  of  potash  solution  and 
bleaching  with  oxalic  acid,  immersion  for  many  minutes  in  i 
to  2000  mercuric  chloride  solution,  bathing  in  nascent  chlorine 
generated  by  covering  the  hands  with  chloride  of  lime  paste 
and  rubbing  with  sodium  carbonate  crystals,  the  author  has 
settled  down  to  the  use  of  95  per  cent,  alcohol  for  the  final  step 
following  the  soap  and  water  scrub.  While  alcohol  is  by  no 
means  a  strong  rapid  germ  destroyer,  it  washes  off  the  soap  and 
sebaceous  secretion  and  actually  gets  to  the  skin  with  its  hair 
and  sebaceous  follicles — something  that  watery  solutions  never 
do^ — and  it  leaves  the  hands  in  perfect  condition  without  crack- 
ing or  destroying  the  skin. 

Sterilization  of  Other  Materials. — All  watery  solutions  to 
be  used  about  the  patient  are  sterilized  by  boiUng  for  20 
minutes.  In  the  absence  of  spore-bearing  bacilli  five  minutes 
is  sufficient,  but  the  absence  of  spore-bearing  organisms  is 
never  taken  for  granted. 

Dirty  water,  even  if  sterile,  should  not  be  used,  filtration  or 
distillation  being  necessary  unless  the  water  was  originally 
clear.  Dead  bacteria  and  bacterial  products  are  not  entirely 
innocuous   as    studies   of    the   production  of   anaphylaxis  are 


ASEPSIS   AND    ANTISEPSIS  569 

constantly  revealing.     All  utensils  for  holding  solutions  should 
be  sterilized  either  by  boihng  or  by  superheated  steam. 

Gloves  may  be  sterilized  in  either  manner,  but  boiling  in  plain 
water  is  sure  if  the  gloves  are  entirely  submerged.  If  steriHzed 
with  the  dressings  in  the  autoclave  the  fingers  should  be  held 
open  by  a  light  stuffing  of  gauze. 

Gowns,  towels,  sheets,  drapes,  and  gauze  sponges  and 
dressings  are  sterilized  in  the  autoclave  or  pressure  sterilizer. 

Bacteriological  standardization  demands  fractional  steam 
sterihzation  for  three  successive  days  in  order  to  allow  time 
for  the  development  of  spores  and  their  destruction  as  fully 
developed  bacilli.  Practically,  this  is  necessary  for  gauze 
sponges  and  dressings  only,  the  preceding  boihng  of  towels, 
sheets,  etc.,  in  the  process  of  laundering,  being  sufficient  to 
destroy  any  previous  contamination. 

Material  to  be  steam-sterihzed  should  be  loosely  packed, 
else  the  steam  fails  to  penetrate  to  the  center  of  the  package 
and  imperfect  sterilization  is  the  result. 

All  instruments  used  in  operating  are  sterilized  by  boiling 
for  20  minutes.  As  plain  water  tends  to  the  formation  of 
spots  and  rust,  a  i  per  cent,  sodium  carbonate  solution  is  used 
instead. 

Knives  and  scissors  are  quickly  dulled  by  boiling,  so  that 
some  surgeons  prefer  to  immerse  them  in  5  per  cent,  carbolic 
solution  previous  to  operating.  This  is  not  safe  unless  the 
scissors  have  aseptic  locks,  and  even  then  it  presents  a  weak 
link  in  an  otherwise  perfect  chain  of  asepsis.  Scissors  should 
be  boiled  with  the  other  instruments,  and  clamps  should  be 
opened  before  boiling.  If  the  jaws  of  clamps  are  closed  so 
that  no  water  enters  between  them  only  dry  heat  sterilization 
is  effected,  and  this  is  wholly  inefficient  below  40o°F. 

Knives  should  be  thoroughly  scrubbed,  washed  with  alcohol, 
the  blades  wrapped  in  cotton  and  boiled  for  three  minutes,  or 
they  may  be  laid  in  liquified  carbolic  acid  for  one  minute  and 
immediately  transferred  to  90  per  cent,  alcohol. 


570  GYNiECOLOGIC   SURGERY 

Silkworm  gut,  silk,  linen,  and  silver  wire,  all  can  be  sterilized 
in  the  steam  sterilizer  by  utilizing  large  ignition  tubes  as  con- 
tainers, in  which  the  suture  material  is  placed  wound  loosely 
and  in  thin  layers  on  spools,  the  tube  then  being  plugged  with 
cotton  as  in  the  bacteriological  laboratory.  Fractional  ster- 
ilization for  one-half  hour  on  three  successive  days  insures 
absolute  steriHty  until  the  tube  is  opened.  Owing  to  the 
possibiHty  of  contamination  after  the  tube  is  opened  and  the 
great  number  of  tubes  which  are  needed  if  this  method  is  carried 
out,  it  is  deemed  preferable  to  boil  such  suture  material  with 
the  instruments,  the  silk  and  Knen  being  loosely  wound  on 
pieces  of  gauze.  Repeated  boiling  destroys  the  tensile  strength 
of  silk  and  hnen,  but  where  daily  operations  are  performed 
the  surgery  nurse  soon  learns  to  estimate  the  approximate 
quantity  of  material  which  it  is  necessary  to  prepare  for  each 
operation. 

The  preparation  and  steriHzation  of  catgut  has  been  the 
hete  noire  of  surgeons  since  its  introduction  as  a  material  for 
sutures  and  ligatures.  As  prepared  from  the  sub-mucosa  of 
the  intestine  of  the  sheep  it  is  originally  contaminated  by  many 
organisms,  the  most  dangerous  being  the  tetanus  bacillus. 
The  difficulty  of  securing  positive  sterihty  has  been  so  great 
that  many  surgeons  either  have  not  used  it  at  all  or  have 
discarded  it  after  a  series  of  disasters.  Its  absorbable  char- 
acter, however,  makes  it  so  desirable  for  use  in  many  regions 
that  constant  effort  has  resulted  in  devising  methods  by  which 
sterility  is  assured.  For  a  description  of  some  of  these  the 
student  is  referred  to  Binnie's  Surgery. 

For  the  occasional  operator,  and  even  for  the  one  who  is 
operating  daily,  it  is  better  to  purchase  catgut  already  ster- 
iHzed  and  preserved  in  breakable  tubes,  unless  he  has  behind 
him  a  well-equipped  laboratory  devoted  to  catgut  preparation, 
and  a  capable  bacteriologist  to  check  up  the  sterility  of  the 
resulting  product.  This  is  impossible  in  any  but  the  largest 
hospitals,  and  while  the  commercially  prepared  gut  is  expen- 


ASEPSIS   AND   ANTISEPSIS  571 

sive,  and  sometimes  very  unsatisfactory,  its  sterility  cannot 
be  questioned  if  supplied  by  reliable  manufacturers.  Some 
undoubtedly  sterile  gut  is  so  over-hardened  as  to  be  practically 
non-absorbable,  and  such  gut  is  frequently  extruded  from  a 
wound  months  after  its  introduction,  while  other  makes  have 
lost  their  tensile  strength  during  the  process  of  preparation. 

Gut  prepared  by  the  Bartlett  process  and  preserved  in  a 
weak  iodine  solution  has  been  found  to  preserve  its  tensile 
strength  remarkably  well,  and  the  finest  strands  are  so  strong 
that  heavy  sutures  and  hgatures  are  not  required.  The  prin- 
cipal objection  to  this  gut  is  the  impossibility  of  boiling  the 
tubes  in  which  it  is  contained,  and  in  order  to  preserve  an 
unbroken  chain  of  aseptic  technique  they  should  be  immersed 
in  strong  carbolic  acid  for  several  minutes  and  then  kept  in 
alcohol  until  used. 

Immersing  the  tubes  in  watery  solution  of  mercuric  chloride 
is  not  safe  unless  the  solution  is  very  strong  and  all  grease  has 
been  removed  previously  by  washing  with  alcohol  or  ether. 

Preservation  of  Sterility. — The  original  sterilization  of  every- 
thing coming  into  contact  with  an  operative  wound  is  com- 
paratively simple;  it  is  in  the  preservation  of  this  condition  of 
sterility  until  the  wound  is  closed  and  the  dressings  applied, 
that  the  technical  aseptic  skill  of  an  operating  room  corps 
must  be  estimated.  To  the  end  that  there  be  no  accidental 
contamination,  all  instruments,  solutions,  trays,  etc.,  should  be 
covered  with  sterile  towels  until  wanted.  The  operator,  as- 
sistants, and  nurses  should  be  covered  from  head  to  foot  by 
sterile  gowns  and  masks.  Nothing  should  be  touched  by  the 
gloved  hands  that  is  not  surgically  clean.  Talking  or  laughing 
over  a  wound  or  over  instruments  should  be  prohibited.  The 
less  the  material  which  goes  into  a  wound,  the  less  the  risk. 
Running  sutures  through  the  fingers,  dipping  them  in  sterile 
water,  frequent  washing  of  the  hands,  etc.,  etc.,  is  likely  to  lead 
to  contamination  through  accidental  soiling  of  water  standing 
open  in  containers;   in  fact  the  simpler  and  more  straight- 


572  GYNiECOLOGIC    SURGERY 

forward  the  entire  operation  the  less  the  risk  of  accidental 
infection. 

In  abdominal  operations  sterile  towels  should  be  pinned  or 
clamped  to  the  edge  of  the  wound  as  soon  as  the  abdomen  is 
opened,  both  to  prevent  possible  infection  from  the  abdominal 
skin  and  the  carrying  of  iodine  into  the  peritoneal  cavity. 

In  vaginal  operations  neatness  and  dexterity  in  keeping  in- 
struments, fingers,  and  sutures  away  from  the  anus  is  imperative 
if  perfect  results  are  to  be  obtained,  and  that  instant,  almost 
instinctive,  revolt  at  contact  with  anything  not  surgically 
clean  which  has  been  dubbed  the  ''aseptic  conscience,"  is 
necessary  in  order  to  secure  uniformly  perfect  results. 

In  one  sense  it  is  unfortunate  that  every  contaminated  wound 
does  not  become  infected  and  break  down,  as  such  an  object 
lesson  would  prevent  the  carelessness  which  is  so  frequently 
engendered  in  surgeons,  assistants,  and  nurses,  by  the  rela- 
tively few  mistakes  in  technique  which  are  followed  by  openly 
bad  results.  One  poor  technician  can  destroy  the  aseptic 
morale  of  an  entire  operating  room  force,  simply  because  his 
patients  rarely  die  and  an  occasional  suppuration  is  regarded  as 
inevitable. 

ANAESTHESIA 

The  most  important  single  consideration  in  the  average  opera- 
tion, so  far  as  concerns  immediate  danger  to  life,  is  the  anaes- 
thetic and  its  administration.  The  technique  of  the  adminis- 
tration of  general  anaesthetics  must  be  learned  both  by  careful 
study  and  by  the  actual  administration  of  the  various  agents 
under  competent  supervision,  and  only  a  general  discussion  of 
anaesthetics  and  their  selection,  their  indications  and  contra- 
indications, will  be  undertaken  here. 

Local  anaesthesia  has  a  limited  field  of  usefulness  in  gynaeco- 
logic  surgery,  but  within  this  field  some  of  its  applications  are 
of  great  importance.  The  three  drugs  most  frequently  used 
are  cocaine,  novocaine,  and  quinine  and  urea  hydrochloride. 


LOCAL   ANESTHESIA  573 

Cocaine  is  the  most  powerful  and  also  the  most  toxic  of  the 
three,  and  its  use  is  becoming  restricted  to  examinations,  such 
as  cystoscopy,  and  operations  like  the  removal  of  urethral 
caruncle,  in  which  its  surface  application  is  sufficient.  A  4 
or  5  per  cent,  solution  applied  to  the  urethra  on  cotton-wrapped 
toothpicks  produces  sufficient  anaesthesia  for  cystoscopy  or  the 
removal  of  small  caruncles  without  pain.  The  hypodermatic 
use  of  cocaine  about  the  urethra  and  vulva  is  extra  hazardous, 
and  in  view  of  the  greater  safety  of  novocaine  it  should  be  dis- 
continued in  favor  of  the  latter  drug.  Incision  of  furuncles, 
Bartholinian  abscesses,  etc.,  is  rendered  painless  by  the  super- 
ficial infiltration  of  the  tissues  with  a  2  per  cent,  novocaine  solu- 
tion. Massive  infiltration  of  infected  areas  with  weak  solu- 
tions of  novocaine  is  contra-indicated  as  it  is  likely  to  spread 
infection,  and  quinine  and  urea  hydrochloride  should  never  be 
used  for  this  purpose.  Cervical  and  perineal  repair  can  be 
effected  under  novocaine  infiltration  without  operative  pain 
if  the  operation  is  performed  rapidly,  but  these  are  operations 
of  election  in  which  primary  wound  healing  is  the  sole  considera- 
tion, and  as  infiltration  anaesthesia  of  any  sort  renders  local 
infection  and  failure  of  union  possible,  it  should  not  be  used  as 
the  anaesthetic  for  plastic  work.  Nerve  blocking  outside  the 
operative  area  is  possible  in  repairing  both  lacerated  cervices 
and  perinei,  but  the  necessity  for  operation  in  such  cases  is 
rarely  so  urgent  that  it  must  be  done  in  the  face  of  contra- 
indications to  general  anaesthesia.  While  the  actual  operative 
work  can  be  rendered  painless,  traction  upon  the  cervix,  drag- 
ging upon  the  vulva,  and  accidental  pricks  with  the  needle, 
render  such  operations  anything  but  comfortable  for  the 
patient. 

The  most  important  indication  for  local  anaesthesia  in  gynae- 
cology is  for  exploratory  incision,  either  through  the  posterior 
vaginal  cul-de-sac  or  anterior  abdominal  wall,  in  patients  who 
are  in  bad  general  condition,  and  for  the  evacuation  of  intra- 


574  GYNECOLOGIC   SURGERY 

abdominal  pus  under  the  same  circumstances  and  through  the 
same  avenues. 

Under  local  anaesthesia  an  occasional  major  abdominal  opera- 
tion can  be  completed  by  a  rapid  operator  without  the  infliction 
of  much  pain,  but  if  the  conditions  found  on  exploration  de- 
mand considerable  intra-abdominal  manipulation  the  quan- 
tity of  general  anaesthetic  needed  is  greatly  reduced,  because 
the  patient  does  not  resist  the  induction  of  anaesthesia.  It  is 
frequently  possible  to  complete  an  operation  before  the  patient 
is  profoundly  anaesthetized,  and  close  the  wound  while  she  is 
recovering. 

This  particular  sequence,  local  followed  by  general  anaesthesia, 
is  life  saving  in  very  severe  septic  conditions,  in  some  ruptured 
extra-uterine  pregnancies,  and  in  patients  with  such  serious 
disease  of  the  heart,  lungs,  or  kidneys  that  full  surgical  anaes- 
thesia is  extra  hazardous. 

Spinal  Anaesthesia. — Spinal  anaesthesia,  induced  by  the  in- 
troduction into  the  subdural  space  of  cocaine,  novocaine,  or 
stovaine  solution,  has  a  very  limited  field  of  usefulness.  In 
the  hands  of  those  expert  in  its  use,  like  Babcock  of  Phila- 
delphia, it  is  satisfactory,  but  the  technique  of  administration 
must  be  carefully  carried  out.  Even  then  its  risks  are  con- 
siderable and  it  is  not  advised  for  general  use.  If  one  employs 
an  expert  anaesthetist  it  must  be  very  rare  that  the  occasion 
will  arise  when  local  anaesthesia,  plus  nitrous  oxide  or  ether, 
is  not  as  safe  and  satisfactory  as  spinal  anaesthesia. 

Inhalation  Anaesthesia.^ — The  three  general  anaesthetics  which 
always  demand  consideration  and  from  which  a  selection  is  to 
be  made  for  the  individual  case  are  ether,  nitrous  oxide,  and 
chloroform. 

Ether. — -Under  ordinary  circumstances  ether  is  the  anaes- 
thetic of  choice.  It  is  not  expensive,  its  administration  is  the 
most  easily  learned  of  the  three,  and  when  properly  given  a 
death  on  the  table  is  almost  unknown.  It  has  the  further  ad- 
vantage that  the  operator  himself  can  to  a  great  extent  super- 


INHALATION  ANESTHESIA  575 

vise  its  administration  without  distracting  his  attention  too 
seriously  from  the  work  at  hand.  It  is  not  to  be  understood  by 
this  that  ether  should  be  given  by  a  novice,  but  only  that  if 
necessary  it  may  be  so  given  with  relative  safety,  sudden  death 
without  ample  warning  being  so  rare  as  to  be  negligible.  The 
comfort  which  an  operator  feels,  and  the  ease  and  smoothness 
with  which  he  does  his  work,  when  the  anaesthetic  is  given  by 
a  trained  anaesthetist,  are  so  superior  that  such  a  person  should 
be  secured  when  at  all  possible. 

Ether  has  some  disadvantages  which  are  peculiarly  its  own. 
It  is  dangerous  when  given  to  an  asthmatic,  and  some  of  the 
difficulties  occasionally  met  which  are  attributed  to  over- 
secretion  of  mucus  are  really  due  to  expiratory  spasm  of  the 
respiratory  muscles,  a  condition  which  is  quickly  overcome  by 
the  substitution  of  chloroform  for  ether. 

Ether  is  dangerous  if  the  patient  has  an  acute  "  cold,"  whether 
nasal,  laryngeal,  or  bronchial,  and  an  emergency  abdominal 
operation  in  a  patient  with  pneumonia  would  be  out  of  the  ques- 
tion if  ether  were  our  sole  anaesthetic  resource. 

The  administration  of  ether  is  followed  so  quickly  by  bron- 
chitis or  broncho-pneumonia  in  a  rather  high  percentage  of 
cases  if  la  grippe,  coryza,  or  bronchitis  is  present,  that  one  must 
assume  that  ether  irritates  the  respiratory  mucosa  sufficiently 
to  cause  a  locus  minoris  resistensia  in  patients  who  might  have 
thrown  off  the  infecton  if  ether  had  not  been  given.  Whether 
this  is  due  to  a  general  lessening  of  the  normal  resistance,  to 
inhalation  of  mucus  and  infected  saliva,  or  to  the  direct  irrita- 
tion of  the  bronchial  mucous  membrane,  is  not  important. 
The  fact  remains  and  must  be  reckoned  with  during  epidemics 
of  infection  of  the  respiratory  tract. 

Ether  is  hazardous  in  nephritics,  especially  in  those  who 
are  the  victims  of  acute  nephritis,  sudden  complete  suppression 
of  urine  being  one  of  the  disasters  which  may  overtake  such  a 
patient  after  ether  has  been  given. 

Ether  is  dangerous  in  uncompensated  heart  lesions  and  myo- 


57^  GYNECOLOGIC    SURGERY 

carditis,  but  so  are  all  the  general  anaesthetics,  and  if  one  must 
be  given  ether  is  safer  than  the  other  two.  It  is  rare,  however, 
that  one  must  operate  under  such  a  handicap,  and  still  more 
rare  that  local  anaesthesia  will  not  suffice  if  an  operation  is 
imperative. 

Even  under  the  most  favorable  conditions  of  general  health, 
ether  has  the  disadvantage  of  being  disagreeable  to  inhale  and 
of  leaving  intense  thirst  and  severe  nausea  in  its  wake.  Efforts 
have  been  made  to  minimize  the  latter  by  stomach  lavage  be- 
fore the  patient  regains  consciousness,  and  by  the  administration 
of  olive  oil  as  soon  as  swallowing  is  possible.  Both  methods 
probably  reduce  the  disagreeable  after-effects,  but  they  cannot 
be  entirely  eliminated  as  some  of  the  nausea  is  central  in  its 
origin. 

In  spite  of  its  drawbacks,  however,  ether  must  be  the  anaes- 
thetic of  choice  in  the  greater  number  of  abdominal  operations, 
because  it  is  much  safer  than  chloroform  and  it  produces 
complete  relaxation,  in  which  respect  it  is  superior  to  nitrous 
oxide. 

Nitrous  Oxide. — The  discovery  many  years  ago  that  nitrous 
oxide  anaesthesia  could  be  maintained  almost  indefinitely,  if 
oxygen  were  administered  simultaneously,  was  not  taken  ad- 
vantage of  until  within  a  very  recent  time.  It  has  been  exten- 
sively advocated  in  the  last  decade,  both  by  those  who  are  scien- 
tifically interested  and  also  by  those  commercially  interested 
in  the  sale  of  the  gas  and  the  apparatus  for  its  administration, 
and  it  is  somewhat  difficult  to  decide  where  scientific  interest 
ceases  and  commercial  interest  and  advertising  begins. 

Having  used  nitrous  oxide  in  approximately  25  per  cent,  of 
his  operative  work  for  the  past  10  years,  the  author  feels  that 
the  following  review  is  based  upon  a  sufficient  knowledge  of  its 
drawbacks  as  well  as  its  advantages.  Briefly,  its  disadvantages 
in  gynaecology  are  that  it  is  the  most  dangerous  of  the  three 
general  anaesthetics  unless  an  anaesthetist  of  wide  experi- 
ence and  special  training  with  nitrous  oxide  is  employed,  and 


INHALATION  ANESTHESIA  577 

unless  the  gas  is  scientifically  prepared  and  chemically 
pure.  When  both  of  these  conditions  are  fulfilled  it  is  the 
safest  anaesthetic  known,  but  even  then  it  is  not,  as  is  so  fre- 
quently stated,  absolutely  safe.  No  agent  of  which  we  have 
any  knowledge  is  perfectly  safe  when  given  to  the  stage  of  com- 
plete unconsciousness.  Nitrous  oxide  is  expensive,  and  to 
many  people  in  moderate  circumstances  the  expense  is  pro- 
hibitive if  sufficient  care  is  taken  in  the  preparation  and  testing 
of  the  gas  to  make  certain  that  dangerous  impurities  are 
absent. 

In  robust  muscular  patients  it  fails  to  produce  reasonable 
relaxation,  and  in  some  marked  rigidity  persists — indeed  there 
are  a  few  individuals  who  cannot  be  anaesthetized  to  the  surgical 
degree  by  nitrous  oxide.  In  abdominal  work  this  rigidity  is 
the  source  of  much  annoyance.  The  wound  edges  are  severely 
bruised  in  efforts  at  keeping  the  incision  open,  and-  the  operator 
is  constantly  hampered  in  his  work  by  his  inability  to  deal 
deftly  and  directly  with  the  organs  to  be  removed.  In  addi- 
tion to  the  muscular  rigidity  itself,  it  is  universal  experience  that 
the  intestine  is  more  markedly  distended  under  nitrous  oxide 
anaesthesia  than  it  is  under  ether  or  chloroform,  and  protruding 
gut  is  always  in  evidence  until  the  operative  field  is  completely 
walled  off  from  the  general  abdominal  cavity.  This  means 
that  the  individual  surgeon  requires  more  time  in  which  to 
perform  a  given  task  than  he  would  if  one  of  the  other  anaes- 
thetics were  employed,  and  in  a  few  cases  too  much  time  means 
a  fatality. 

In  connection  with  this  it  must  be  stated  that  something, 
either  the  oxygen  administered  or  the  carbon  dioxide  retained, 
stimulates  the  patient  while  anaesthesia  is  maintained,  and  this 
occasionally  leads  to  puttering  slow  work  and  collapse  after  the 
patient  is  returned  to  bed.  It  is  possible  that  some  of  the 
tendency  to  collapse  is  brought  about  by  the  almost  instant 
awakening,  so  that  the  patient  is  fully  conscious  in  a  few  minutes 
after  the  anaesthetic  is  withdrawn  and  therefore  is  subject  to 

37 


578  GYNECOLOGIC   SURGERY 

more  intense  pain  than  during  the  slow  awakening  from  full 
ether  anaesthesia.  On  awakening  after  nitrous  oxide  anaesthesia 
the  patient  may  be  fully  conscious  before  analgesia  disappears, 
and  often  she  will  state  that  she  is  perfectly  comfortable  before 
leaving  the  operating  room,  while  a  look  at  her  in  bed  30 
minutes  later  reveals  a  totally  different  picture. 

The  above  criticisms  apply  to  pure  nitrous  oxide-oxygen 
anaesthesia,  but  they  are  materially  modified  by  a  full  dose  of 
opiate  preceding  its  administration,  and  the  use  of  a  small 
quantity  of  ether  from  time  to  time  throughout  the  duration  of 
the  anaesthesia. 

So  far  as  the  author  knows  there  is  no  nitrous  oxide  apparatus 
in  general  use  which  does  not  have  an  accessory  ether  container 
by  which  a  varying  percentage  of  ether  vapor  can  be  added  to 
the  other  gas,  and  in  abdominal  work  this  is  almost  universally 
used  although  the  casual  observer  may  not  be  aware  of  it. 

By  this  addition  the  most  satisfactory  type  of  anaesthesia 
can  be  maintained,  and  the  quantity  of  ether  used  is  not  great 
enough  to  cause  the  prolonged  disagreeable  after-effects  of  a 
pure  ether  anaesthesia,  its  only  drawbacks  being  the  expense 
and  the  necessity  for  an  expert  nitrous  oxide  anaesthetist. 

Nitrous  oxide-oxygen  is  the  anaesthetic  of  choice  for  short 
maneuvers,  like  curettage  and  evacuating  abscesses;  it  is  also 
the  anaesthetic  of  choice  for  plastic  work  about  the  cervix  and 
vagina,  as  the  after-pain  is  not  severe. 

Combined  with  ether  in  proper  proportions  it  can  be  used 
for  any  operative  procedure  in  the  abdomen,  but  is  much  more 
frequently  chosen  when  the  patient  is  for  any  reason  far  below 
par,  or  the  victim  of  bronchitis  or  nephritis.  Very  large  tumors, 
which  distend  the  abdominal  cavity  and  stretch  the  abdominal 
wall,  can  be  removed  as  readily  under  nitrous  oxide  as  under 
ether  since  the  abdominal  muscles  are  not  especially  rigid  after 
the  tumor  is  delivered,  but  the  removal  of  tubes  and  ovaries 
which  are  adherent  to  the  bottom  of  the  pelvis  is  accomplished 
in  half  the  time  under  ether  that  is  required  under  gas.     Ex- 


INHALATION  ANESTHESIA  579 

ploration  of  the  entire  abdomen  is  never  accomplished  unless 
ether  in  considerable  amounts  is  given  to  the  patient  while  the 
examination  is  proceeding. 

Very  long  single  operations,  or  a  series  of  operations  which 
require  much  time  for  their  performance,  are  best  performed 
under  nitrous  oxide-oxygen-ether  anaesthesia,  as  it  is  after  pro- 
longed ether  anaesthesia  that  its  disastrous  effects  are  most 
likely  to  be  manifested. 

To  summarize:  Nitrous  oxide-oxygen  anaesthesia  is  devoid 
of  most  of  the  disagreeable  after-effects  of  chloroform  and 
ether.  It  is  safer  when,  and  only  when,  pure,  and  administered 
by  an  expert.  It  produces,  per  se,  less  depression  than  chloro- 
form or  ether  in  patients  below  par  in  general  health.  It  does 
not  irritate  the  respiratory  tract  or  kidneys.  Once  the  patient 
is  safely  under  its  administration  can  be  kept  up  almost  in- 
definitely without  harm  from  the  anaesthetic  itself. 

On  the  other  hand,  it  is  expensive,  it  does  not  produce  mus- 
cular relaxation,  and  it  thus  favors  incomplete,  imperfect  work 
in  the  abdomen.  Unless  some  form  of  local  anaesthesia  or 
large  doses  of  opiates  are  used  in  addition,  the  patient  suffers 
pain  from  the  early  awakening,  providing  the  operation  itself 
is  productive  of  after-pain. 

The  addition  of  a  minimum  quantity  of  ether  to  nitrous 
oxide  rids  it  of  most  of  its  inconveniences  excepting  the  expense 
and  the  necessity  for  an  expert  gas  anesthetist. 

Chloroform. — Chloroform  labors  under  the  same  disad- 
vantages that  nitrous  oxide  does  as  regards  the  necessity  for 
an  expert  administrator,  and  even  then  sudden  death  is  far 
too  common  to  render  its  use  safe  in  northern  latitudes.  It 
is  still  quite  popular  in  the  South,  and  it  is  possible  that  its  more 
rapid  evaporation  renders  an  over-dose  less  probable  in  warm 
climates  than  in  cold.  Nitrous  oxide  acts  so  well  under  cir- 
cumstances which  forbid  the  use  of  ether  that  about  the  only 
indication  left  for  chloroform  is  an  operation  of  necessity 
upon  an  asthmatic  patient. 


580  GYNiECOLOGIC   SURGERY 

Mixed  General  and  Local  Anaesthesia  on  the  Anoci- Associa- 
tion Theory  of  Crile. — This  subject  may  equally  well  be  dis- 
cussed here  or  in  connection  with  the  question  of  surgical  shock, 
as  its  development  was  brought  about  by  Crile's  well-known 
theory  that  shock  is  produced  by  sensory  stimuli  which  exhaust 
certain  nerve  cells  in  the  brain  through  over-stimulation,  thus 
leading  to  the  subsequent  depression  and  vaso-motor  paresis 
which  goes  under  the  clinical  name  of  shock.  In  the  effort  at 
developing  a  method  by  which  this  might  be  prevented, 
nerve  blocking  was  utilized  by  means  of  local  anaesthesia  of  the 
area  to  be  attacked,  novocaine  in  i  to  400  dilution  being  used 
to  infiltrate  extensively  about  the  proposed  line  of  incision. 
Certain  intra-abdominal  structures,  such  as  the  mesentery 
of  the  appendix  and  the  broad  ligaments,  were  further  in- 
filtrated, sometimes  before  and  at  other  times  after  the  pedicles 
were  tied.  As  novocaine  anaesthesia  lasts  but  a  very  short 
time,  15  to  30  minutes,  it  is  apparent  that  such  infiltration  could 
have  only  a  momentary  effect,  so  that  solutions  of  quinine  and 
urea  hydrochloride  were  resorted  to  in  the  abdominal  wall,  the 
parietal  sub-peritoneal  tissue,  and  in  all  available  ligaments,  in 
an  effort  to  prevent  the  conveyance  of  sensory  impulses  to  the 
brain. 

Two  facts  seem  to  have  been  conclusively  proven  by  Crile's 
experience:  one,  that  there  is  less  post-operative  pain;  another, 
that  post-operative  elevation  of  pulse  and  temperature,  the 
so-called  aseptic  wound  fever,  are  somewhat  lessened  by  this 
procedure. 

That  it  materially  minimizes  shock  in  pelvic  operations  is 
open  to  debate,  as  but  an  extremely  limited  number  of  such 
operations  are  productive  of  sufficient  shock  to  be  clinically 
recognizable  providing  a  bloodless  operation  is  performed, 
and  in  those  cases  in  which  shock  is  most  to  be  feared  this 
method  is  not  available,  or  at  best  to  but  a  limited  degree. 
In  gynaecology,  operations  performed  for  profound  sepsis,  for 
ruptured  ectopic  pregnancy,  and  for  carcinoma  of  the  uterus, 


INSTRUMENTS  58 1 

are  the  ones  in  which  shock  is  to  be  apprehended.  According 
to  the  author  of  this  method,  quinine  and  urea  hydrochloride 
must  not  be  used  in  infected  tissues  or  those  to  be  drained, 
and  it  is  thus  ruled  out  from  the  first.  In  the  radical  hys- 
terectomy necessary  for  carcinoma,  nerve  blocking  to  an  effi- 
cient extent  is  difficult  if  not  impossible,  and  in  all  three  the 
added  time  necessary  for  the  complete  nerve  blocking,  upon 
which  the  author  insists,  might  in  itself  turn  the  scale  against 
the  patient's  recovery. 

The  effect  of  massive  tissue  infiltration  upon  wound  healing, 
especially  with  quinine  and  urea  hydrochloride,  is  questionable. 
The  author  of  the  method  states  that  it  lowers  the  resistance  of 
the  tissues  so  that  wound  infection  is  more  easily  produced. 
The  lessened  post-operative  elevation  of  pulse  and  temperature 
can  be  explained  upon  the  hypothesis  of  lessened  absorption 
through  the  lymphatics  leading  from  wounds  which  are  com- 
pressed by  a  brawny  exudate,  as  well  as  by  any  other.  That 
unconsciousness  may  be  present  while  nerve  conductivity  re- 
mains active  is  definitely  proven  by  reflex  acts  during  anaes- 
thesia, twitching  of  muscles  when  their  motor  nerves  are  irri- 
tated, etc.  As  a  method  of  anaesthesia  which  possibly  lessens 
shock  it  very  definitely  deserves  a  trial  as  soon  as  its  contra- 
indications are  plainly  stated  by  those  surgeons  who  have  used 
it  extensively,  but  until  this  is  done  it  should  be  used  with 
caution,  as  post-operative  pain  is  readily  overcome  by  safe  doses 
of  morphine,  and  a  narcotic  plus  perfect  wound  healing  is  pref- 
erable to  quinine  and  urea  locally  without  a  narcotic,  if  the 
latter  necessitates  sloughing  wounds  and  post-operative  hernia. 

INSTRUMENTS 

The  instruments  used  in  gynaecologic  surgery  are  those  used 
in  surgery  generally,  with  the  addition  of  such  as  are  required 
to  gain  access  to  the  uterus  and  upper  part  of  the  vagina. 
Perineal  retractors  of  various  types  are  used  for  the  latter 


582 


GYNECOLOGIC   SURGERY 


purpose.  Dilators  and  long-handled  curettes  are  necessary  for 
gaining  access  to  the  cavity  of  the  uterus  and  for  removing  its 
mucosa,  whether  for  diagnostic  or  therapeutic  purposes. 

Knives,  scissors,  haemostats,  long-handled  clamps,  retractors, 
volsellum  forceps,  needles  and  needle  holders,  are  the  same  as 
are  utilized  in  general  operations  upon  the  organs  in  the  ab- 


FiG.  257. — Method  of  using  author's  modification  of  Beck's  spoon  as  a  retractor 

and  light  reflector. 


dominal  cavity.  Special  needles  for  cervical  repair  are  of  no 
great  advantage,  but  no  abdominal  operation  should  be  under- 
taken without  a  sufficient  number  of  small  round  needles  for 
possible  work  upon  the  intestine. 

The  author  has  devised  a  modification  of   the  well-known 


INCISIONS 


583 


Beck's  spoon  by  broadening  the  blade,  lessening  its  concavity, 
and  turning  the  handle  away  from  the  blade  at  an  angle  of 
45  degrees,  which  renders  it  an  excellent  intra-abdominal 
retractor  and  an  efhcient  light  reflector  as  well.  Clamps  with 
detachable  handles,  such  as  those  devised  by  Pryor,  are  very 
useful  if  vaginal  hysterectomy  is  to  be  performed  by  the  clamp 
method. 

While  a  sufficient  number  of  the  instruments  required  should 
always  be  at  hand,  a  multiplicity  of  special  instruments,  devised 
for  every  possible  contingency,  is  not  advised. 


INCISIONS 


The  object  of  the  abdominal  incision  is  to  secure  an  avenue  of 
approach  to  the  structures  to  be  dealt  with  and  no  other  con- 


FiG.  258. — ^Line  of  transverse  abdominal  incision.     Devised  by  Pfannenstiel. 

sideration  is  of  equal  importance,  but  the  factors  of  injury  to 
muscles,  fascia,  and  nerves  should  be  taken  into  account,  as 
well  as  the  possibility  of  accurate  suturing  at  the  close  of  the 
operation  proper.  A  crescentic  incision,  concavity  upward, 
through  the  skin  and  superficial  fascia  at  or  below  the  superior 
margin  of  the  mons  pubis,  followed  by  dissection  of  the  flap, 
a  transverse  fascial  incision,  and  a  longitudinal  incision  through 
the  peritoneum,  is  favored  by  many.     This  presents   no  ad- 


584 


GYNiECOLOGIC   SURGERY 


vantage  save  the  avoidance  of  a  skin  scar,  and  it  seriously  re- 
stricts the  working  space  in  the  event  that  unexpected  diffi- 
culties are  encountered.  In  selected  cases,  however,  this  in- 
cision devised  by  Pfannenstiel  gives  a  remarkably  aesthetic 
result. 

The  best  all  around  incision  for  pelvic  work  is  a  median  skin 
incision  whose  inferior  extremity  reaches  nearly  to  the  pubis, 


Fig.  259. — Transverse  abdominal  incision.     Incision  through  deep  fascia. 

and  whose  length  is  in  accordance  with  the  nature  of  the  case. 
It  should  be  made  with  firm  sweeps  of  the  scalpel  until  the 
sheath  of  the  rectus  is  encountered,  when  a  short  cut  through 
one  end  of  this  is  made.  This  is  rapidly  enlarged  with  the 
scissors,  as  being  less  likely  to  cut  underlying  muscle  inad- 
vertently than  the  knife.  The  muscle  is  split  or  pushed  aside 
with  the  closed  scissors  until  the  sub-peritoneal  fat  is  exposed. 


INCISIONS 


585 


Occasionally,  when  the  abdominal  wall  is  thin,  the  linea  alba 
is  cut  down  upon  directly  and  then  the  knife  deepens  the  in- 
cision rather  than  the  scissors. 


Fig.  260. — Transverse  abdominal  incision.     The  fascia  cut  transversely,  the 
recti  muscles  drawn  apart,  the  peritoneum  opened  longitudinally. 

Much  dissecting  between  fatty  layers  can  be  avoided  if  the 
sub-peritoneal  fat  is  opened  with  a  sharp  knife,  but  care  is  neces- 
sary not  to  penetrate  the  peritoneum  and  injure  the  intestine. 
After  the  peritoneum  is  exposed,  it  is  caught  with  a  hasmostat 


586  GYNECOLOGIC   SURGERY 

and  a  sufficiently  large  fold  drawn  up  to  permit  the  finger  to  be 
placed  at  one  side  below  the  forceps.  Thus  one  makes  sure 
that  nothing  more  than  a  double  fold  of  peritoneum  is  present 
over  the  finger,  and  this  fold  may  be  quickly  incised  without 
danger  to  underlying  viscera.  At  the  first  nick  through  the 
peritoneum  air  rushes  in  and  the  intestine  drops  away. 

The  peritoneal  incision  is  enlarged,  to  the  extent,  of  that 
through  the  muscle,  care  being  taken  that  the  bladder  is  not 
injured  at  the  lower  end  of  the  incision.  In  patients  with  large 
tumors  the  peritoneum  is  first  opened  at  the  upper  end  of  the 
incision,  and  it  is  not  extended  so  near  to  the  pubis  until  the 
location  of  the  bladder  is  definitely  ascertained.  If  difficulty  is 
experienced  in  securing  enough  room  for  proper  manipulation, 
the  muscles  and  fascia  may  be  incised  longitudinally  hard  against 
the  pubis,  and  an  additional  transverse  nick  made  at  the  inferior 
extremity  of  the  pyramidalis  muscle.  The  bladder  is  in  no 
danger  of  injury  if  this  incision  is  no  deeper  than  the  internal 
surface  of  the  muscle.  Rarely,  it  may  be  necessary  to  incise 
one  or  both  recti  transversely  at  a  higher  level  in  order  to 
secure  room  for  the  separation  of  adhesions  or  to  get  behind  a 
tumor  for  the  provisional  control  of  hemorrhage.  In  such  an 
event  the  rectus  should  be  securely  attached  to  its  sheath  by 
mattress  suture  above  and  below  the  proposed  incision  before 
the  muscle  is  cut,  as  by  so  doing  retraction  of  the  muscle  is 
prevented  and  perfect  closure  is  assured.  Should  it  be  neces- 
sary to  extend  an  incision  above  the  umbilicus,  the  latter  should 
not  be  cut  through  but  skirted  on  one  side  or  entirely  removed. 
Incisions  in  either  the  right  or  left  hypogastric  region  can  be 
made  in  accordance  with  those  devised  for  access  to  the  appendix. 

HEMOSTASIS 

Ha^mostasis  is  effected  by  pressure  with  forceps  which 
crush  the  ends  of  the  vessels,  or  by  ligatures  and  sutures  which 
occlude  them.  Crushing  gives  ample  security  for  very  small 
vessels  but  it  should  not  be  depended  upon  for  anything  larger 


HiEMOSTASIS  587 

than  muscular  twigs,  and  minor  annoyances  from  post-operative 
haematomata  can  be  avoided  if  every  vessel  which  spurts  is 
finally  closed  by  a  string  around  it.  Imperfect  haemostasis  is 
responsible  for  more  disasters  after  abdominal  operations  than 
is  generally  acknowledged,  many  cases  of  shock  being  nothing 
more  nor  less  than  post-operative  bleeding,  and  many  instances 
of  post-operative  sepsis  being  due  primarily  to  a  haematoma  or 
haematocele  which  furnished  an  excellent  culture  medium. 
Bizarre  methods  of  controlling  hemorrhage  by  huge  crushing 
clamps  like  the  angio-tribe  and  by  electro-cauterizing  ap- 
paratus, may  be  efficient  but  they  are  clumsy,  unsurgical,  and 
unnecessary,  since  the  ordinary  means  at  our  command  are 
perfectly  safe  and  are  always  available.  Heat  and  pressure 
are  rehed  upon  to  check  oozing  from  raw  surfaces  on  which 
no  large  vessel  is  open,  both  being  apphed  by  means  of  pads 
wrung  out  of  water  as  hot  as  the  hands  can  tolerate  momen- 
tarily. Oozing  in  the  pelvis,  not  controlled  by  the  pressure 
of  hot  gauze  applied  for  a  few  moments  only,  should  be  met  by 
a  gauze  pack  led  out  through  the  vagina.  This  drains  the 
serum  from  the  blood  as  fast  as  it  is  poured  out  and  promotes 
coagulation;  more  than  all,  it  prevents  the  formation  of  haem- 
atomata and  obviates  the  necessity  for  secondary  cul-de-sac 
incision  when  the  patient  should  be  well  on  the  road  to  recovery. 
Persistent  oozing  from  raw  surfaces  in  jaundiced  patients,  or 
those  in  whom  for  any  reason  the  coagulability  of  the  blood  is 
lessened,  is  frequently  controlled  by  the  subcutaneous  intro- 
duction of  an  alien  blood  serum.  Direct  and  indirect  blood 
transfusion  offers  one  method  of  accomplishing  this,  but  the 
subcutaneous  use  of  horse  or  rabbit  serum,  which  is  obtainable 
commercially,  seems  to  be  equally  reliable  and  requires  no 
elaborate  technique. 

SUTURE   AND    LIGATURE   MATERIAL 

For  Kgatures,  silk,  linen,  and  catgut  are  available,  and  of 
these  catgut  is  usually  chosen  because  its  absorption  is  certain 


588  GYNiECOLOGIC   SURGERY 

no  matter  where  it  is  buried,  and  late  extrusion  of  a  sterile 
plain  catgut  knot  is  unknown.-  It  is  especially  important  to 
use  catgut  ligatures  when  drainage  or  infection  is  anticipated. 
So  trivial  an  infection  as  to  do  no  damage,  and  give  rise  to  no 
symptoms,  will  nevertheless  infect  a  silk  or  linen  ligature  and 
lead  to  persistent  suppuration  until  it  is  removed  or  discharged. 
The  smallest  ligature  that  will  afford  sufficient  tensile  strength 
should  be  chosen,  but  the  size  is  not  of  so  much  importance  in  a 
ligature  as  in  a  suture,  as  ligatures  of  plain  gut  are  most  fre- 
quently used,  while  sutures  are  often  hardened.  For  tying 
large  vessels  in  the  abdomen,  however,  slightly  hardened  gut 
is  preferable  to  plain,  as  the  peritoneum  may  digest  the  gut  so 
rapidly  as  to  permit  re-opening  of  the  vessel  lumen  with  second- 
ary hemorrhage  as  a  result.  On  large  vessels  a  thin  silk  or 
linen  ligature  gives  one  a  sense  of  security  never  felt  when  cat- 
gut is  used,  both  because  of  the  certainty  that  the  vessel  is 
properly  tied  and  also  because  the  ligature  will  not  soften. 

The  same  principles  apply  to  buried  sutures  as  to  ligatures, 
excepting  that  apposition  between  tissues  must  be  continued 
longer  to  assure  perfect  union.  All  but  the  largest  vessels  are 
safe  after  48  hours,  while  muscle  and  fascia  require  from  15 
to  20  days  to  be  restored  to  a  degree  of  solidity  approaching 
the  original.  Unless  catgut  is  of  extraordinary  size  it  softens 
much  sooner  than  this,  so  that  gut  which  is  hardened  to  resist 
absorption  for  from  10  to  30  days  is  chosen  for  sutures  buried 
in  muscle  and  fascia.  Fine  silk  and  linen  rarely  give  rise  to 
trouble  in  wounds  which  are  perfectly  sterile,  and  again  the 
certainty  that  they  tie  right  and  remain  for  months  has  led  to 
their  continued  use  by  some  operators.  As  with  ligatures, 
silk  sutures  give  a  sense  of  security  that  is  never  felt  when 
catgut  is  used.  This  is  especially  true  in  post-operative  and 
umbilical  herniotomy  in  which  considerable  tension  is  almost 
certain  to  exist,  but  for  universal  use  fine  hardened  catgut 
meets  practically  all  the  indications.  Coarse,  over-hardened 
gut,  on  the  contrary,  gives  rise  to  more  trouble  than  fine 


SUTURE   AND   LIGATURE   MATERIAL  589 

silk  or  linen.  It  resists  absorption  almost  indefinitely,  and 
the  size  of  the  strand  is  such  that  it  becomes  encysted  with 
difficulty  and  is  likely  to  provoke  localized  suppuration  months 
after  its  introduction.  There  are,  however,  certain  localities 
in  which  the  indications  for  a  particular  suture  material  are 
clear.  Thus,  in  repairing  intestinal  injuries  fine  silk  or  linen 
should  always  be  used,  first,  because  the  suture  as  well  as  the 
needle  carrying  it  must  be  so  fine  as  not  to  tear  or  otherwise 
damage  the  intestinal  wall,  and  second,  because  an  absolutely 
reliable  suture  which  will  hold  for  at  least  five  days  is  necessary. 
In  intestinal  resection  the  inner  row  of  stitches  may  well  be 
of  gut,  but  the  peritoneal  row  of  Lembert  stitches  should  be 
fine  silk  or  linen.  In  uretero-ureteral  or  uretero-vesical 
anastomosis  fine  silk  or  linen  should  be  used  for  the  same 
reason.  In  repairing  bladder  injuries  the  inner  row  of  sutures 
should  be  plain  gut  as  concretions  readily  form  on  a  non- 
absorbable suture. 

Superficial  sutures  may  be  catgut,  silk,  linen,  silver  wire, 
or  silkworm  gut.  On  surfaces  which  are  readily  sterilized  and 
kept  dry,  cagut  is  as  good  as  non-absorbable  material  providing 
it  is  not  under  tension,  but  all  three  of  these  conditions  must  be 
fulfilled  if  its  use  is  to  be  satisfactory.  Macerated  catgut  on 
an  imperfectly  sterilized  surface  furnishes  an  excellent  culture 
medium  and  frequently  gives  rise  to  stitch  abscess.  Silk  and 
linen  are  but  little  better  as  they  absorb  and  retain  moisture 
by  their  capillarity. 

Sutures  which  penetrate  the  skin  surface  should  be  non- 
absorbable and  possessed  of  no  capillarity,  when  there  is  any 
tension,  when  the  surface  is  moist  as  from  drainage,  or  imper- 
fectly sterilized  as  about  the  vulva.  It  is  under  these  cir- 
cumstances that  silkworm  gut  and  silver  wire  find  their  prin- 
cipal use,  and  of  the  two  silkworm  is  generally  chosen  as  it  is 
more  readily  manipulated  and  tied  than  wire.  Deep  tension 
sutures  should  be  coarse,  skin  sutures  the  finest  possible. 

Catgut  sizes:  Catgut  No.  i  is  the  size  most  generally  used; 


590 


GYNECOLOGIC    SURGERY 


No.  o  is  sufficiently  small  for  any  use  to  which  catgut  can  be 
applied  and  size  No.  2  need  never  be  exceeded. 

English  twisted  silk  Nos.  o,  i  and  2  should  always  be  in  stock; 
finer  than  No.  o,  for  blood-vessel  work  can  be  obtained  by  un- 
twisting the  strands  of  which  it  is  composed,  and  No.  2  is  large 
enough  for  any  purpose. 

Linen  should  be  chosen  in  the  sizes  which  correspond  to 
that  given  for  silk,  but  its  numbers  are  not  uniform. 


TYING   LIGATURES   AND   SUTURES 

Most  ligatures  are  tied  with  both  hands,  but  the  primary 
knot  in  a  continuous  suture,  or  repeated  knots  in  an  interrupted, 


Fig.  261. — "Granny  knot." 


Fig.  262. — Reef  or  square  knot. 


can  be  tied  with  one  hand  and  thus  save  the  necessity  for 
dropping  instruments  while  tying.  The  "granny"  knot,  reef 
knot,  triple  knot,  and  surgeon's  knot,  all  give  security  when 

silk  is  used  providing  the  ends  are 
left  sufficiently  long  and  the  knot 
actually  is  tied  down  hard,  but  the 
"granny"  knot  will  sometimes  slip 
under  tension  when  catgut  is  used. 
It  is  better,  therefore,  to  accustom 
oneself  to  the  use  of  the  other  forms, 
of  which  the  reversed  surgeon's  knot 
is  the  best  if  not  tied  under  tension.  The  first  single  turn  can 
always  be  tied  down  hard  and  the  second  double  turn  will 
then  hold  it  safely.  If  there  is  considerable  tension  to  be  over- 
come, as  in  suturing  the  abdominal  fascia  when  the  patient  is 


Fig.  263. — Surgeon's  knot. 


CLOSING  INCISIONS 


591 


taking  the  anaesthetic  badly,  the  first  single  turn  may  slip  while 
the  second  is  tying,  and  here  the  double  turn  should  be  taken 
first. 

The  accompanying  illustrations  show  the  various  knots  better 
than  a  wordy  description.  Of  the  many  ways  of  tying  knots 
with  one  hand,  the  best  is  shown  in  the  illustrations  in  Monk's 
article  in  the  Annals  of  Surgery,  but  rapidly  tied,  one-hand 
knots  should  not  be  depended  upon  to  control  large  vessels. 

Attention  is  again  called  to  the  great  importance  of  leaving 
long  ends  projecting  from  catgut  knots,  as  the  latter  untie 
with  great  ease  when  cut  very  short,  and  many  feet  of  catgut 
do  not  equal  one  life. 

CLOSING  INCISIONS 

The  object  of  wound  suturing  is  to  bring  similar  parts  into 
apposition  and  retain  them  there  until  the  union  which  has 


Fig.  264.  Fig.  265. 

Correctly  placed  through-and-through  stitch. 

taken  place  is  of  sufficient  strength  to  prevent  separation. 
Incidentally  the  obliteration  of  dead  spaces  should  also  be 
obtained.  For  this  purpose  through- and- through  sutures 
taking  in  all  the  wound  layers,  or  suture  of  each  layer  separately, 
or  a  combination  of  these  may  be  used. 

Through-and-through  sutures  are  the  more  rapidly  placed, 
but  owing  to  defects  in  their  introduction  they  frequently  fail 
to  approximate  Hke  structures,  and  often  leave  the  middle 
layers  of  abdominal  wounds  entirely  apart.     They  should  be 


592 


GYNECOLOGIC    SURGERY 


used  only  when  rapidity  is  imperative  because  of  the  bad  general 
condition  of  the  patient,  and  the  mid-portion  of  the  stitch 
should  always  be  farther  from  the  edge  of  the  wound  than  is 
its  point  of  entrance  or  exit. 

On  the  other  hand,  layer  sutures  are  usually  of  catgut,  and 
this  material  is  not  absolutely  rehable  under  tension.  Tension 
on  abdominal  stitches  is  certain  to  be  present  during  retching 
and  vomiting  attacks,  as  well  as  when  the  patient  strains  in 
evacuating  the  bowels.  Haematomata  between  the  layers  of 
the  abdominal  wall  are  common  when  layer  sutures  alone  are 
used,  as  they  approximate  the  edges  of  the  incision  but  not  the 


Fig.  266. — Correct  placing  of  a 
through-and-through  stitch. 


Fig.  267. — Gaping  middle  layers  of 
wound  after  tying  incorrectly  placed 
through-and-through  stitch. 


flat  sides  of  the  various  abdominal  coats.  A  combination  of 
the  layer  suture  with  two  or  three  deep  sutures  extending 
through  the  entire  thickness  of  the  abdominal  wall,  excepting 
the  peritoneum,  takes  the  tension  off  the  wound  edges  and 
approximates  the  layers  at  either  side  of  the  incision.  These 
deep  tension  sutures  should  be  tied  over  a  gauze  roll  to  provide 
elasticity  and  prevent  cutting  the  skin.  Through-and-through 
stitches  of  necessity  are  interrupted,  but  buried  stitches 
may  be  either  interrupted  or  continuous.  Interrupting  buried 
stitches  results  in  burying  many  knots,  and  interrupted  stitches 
are  less  rapidly  applied  than  continuous,  so  that  the  latter 
is  usually  chosen.  In  a  long  wound  an  occasional  knot  is 
judicious,  so  that  the  entire  layer  will  not  fall  apart  if  the  suture 
material  should  break  in  any  part  of  its  course.     In  wounds 


DRAINAGE  593 

likely  to  become  infected,  interrupted  layer  stitches  are  better 
than  continuous  as  infection  of  one  stitch  does  not  damage  the 
entire  series.  This  applies  especially  to  abdominal  operations 
in  which  the  incision  has  been  contaminated  by  the  evacuation 
of  pus  which  of  necessity  soils  the  wound.  A  cardinal  point 
in  the  closure  of  all  wounds  is  that  no  more  tension  should  he 
made  upon  the  stitches  than  is  necessary  to  secure  approximation. 
While  the  tension  varies  under  different  circumstances  the 
principle  is  always  the  same,  and  no  method  of  skin  sterili- 
zation will  prevent  stitch  abscess  if  tissue  is  devitalized  by  the 
pressure  necrosis  of  a  tight  suture.  Metal  clamps  for  closing 
the  skin  edges  are  popular  with  some  operators  and  adhesive 
straps  with  others,  but  any  advantages  they  may  have  are  so 
slight  as  to  be  negligible,  and  both  introduce  undesirable  fea- 
tures— the  first,  multiplicity  of  apparatus;  the  second,  uncer- 
tainty in  sterilization. 

DRAINAGE 

Surgical  drainage  is  always  a  moot  subject,  the  fact  being 
that  v/e  have  no  definite  knowledge  of  when  to  and  when  not  to 
drain.  This  is  especially  true  in  the  abdominal  cavity,  whose 
peritoneal  coat  has  a  tremendous  capacity  for  absorption  and 
whose  serous  exudate  possesses  unknown  antitoxic  power.  The 
facts  that  the  absorptive  power  in  the  individual  case  is  an 
unknown  quantity  and  that  there  is  no  means  of  estimating  the 
resistance,  doubtless  lead  us  to  drain  unnecessarily.  Never- 
theless, a  properly  applied  drain  does  no  harm,  and  an  omission 
to  drain  may  be  fraught  with  fatal  consequences.  Drainage 
may  be  classed  in  two  categories,  prophylactic  and  curative. 

A  prophylactic  drain  should  be  used  in  a  very  fat  abdominal 
wall  in  order  to  remove  serum  and  exuding  fat  which  may 
absorb  slowly  or  not  at  all.  Dead  serum  readily  becomes 
infected,  and  as  asepsis  is  relative  rather  than  absolute,  drain- 
age may  prevent  abscess  formation  under  such  circumstances. 
A  drain  to  remove  blood  exuding  from  large  raw  areas  in  the 
38 


594  GYNECOLOGIC    SURGERY 

abdominal  or  pelvic  cavity  may  likewise  prevent  infection, 
as  such  areas  are  usually  made  during  the  removal  of  densely 
adherent  structures  whose  adhesions  spell  previous  infection 
and  whose  sterility  at  the  time  of  operation  may  be  in  doubt. 
The  separation  of  such  adhesions  almost  certainly  has  damaged 
the  peritoneal  coat  of  the  bowel  sufiiciently  to  permit  the  pas- 
sage of  micro-organisms  through  it,  and  the  abdomen  has  been 
open  sufficiently  long  to  allow  the  introduction  of  many 
saprophytes  whose  presence  in  a  dead  space  full  of  blood 
may  prove  disastrous.  On  the  contrary,  drainage  is  wholly 
unnecessary  when  a  ruptured  tubal  pregnancy  has  left  large 
quantities  of  blood  in  the  abdomen,  because  the  serous  surface 
is  uninjured,  adhesions  are  recent  and  traumatic  in  origin, 
and  no  infection  is  likely  to  be  introduced  in  the  short  operation 
needed  to  remove  a  bleeding  tube.  A  prophylactic  drain 
may  also  be  placed  about,  hut  not  upon,  an  injured  rectum  whose 
lumen  has  been  opened  during  the  separation  of  adhesions,  if 
the  gut  is  in  such  condition  that  there  is  doubt  whether  the 
sutures  inserted  for  its  repair  will  hold.  Prophylactic  drainage 
is  wise  about  areas  soiled  by  virulent  pus,  infected  urine,  or 
fecal  matter.  In  both  the  preceding  examples,  not  only  is  the 
drainage  desirable  but  a  cofferdam  is  constructed  between  the 
suspicious  territory  and  uncontaminated  areas.  The  indications 
for  drainage  for  curative  purposes  are  more  easily  defined. 
Pelvic  or  abdominal  abscesses  which  are  opened  in  order  to 
evacuate  their  contents  need  a  drain  to  maintain  the  patency 
of  the  opening.  These  drains  many  times  should  be  cofferdams 
as  well,  since  the  pus  must  flow  between  coils  of  non-adherent 
intestine  and  the  introduction  of  a  tube  will  not  prevent  con- 
tamination of  the  free  abdominal  cavity,  even  though  intra- 
abdominal pressure  does  tend  to  force  any  material  in  the  ab- 
domen through  an  opening  in  the  parieties.  Such  a  cofferdam 
is  judicious  about  the  area  from  which  a  densely  adherent 
badly  infected  appendix  has  been  removed,  even  if  no  pus  is 
present,  as  infection  and  pus  are  by  no  means  synonymous 


DRAINAGE 


595 


terms.  The  outward  flow  of  serum  through  such  a  drain  cer- 
tainly is  safer  than  trusting  too  much  to  the  action  of  the  pa- 
tient's opsonins  and  leucocytes,  as  one  is  in  doubt  of  their 
efficiency  when  they  permit  the  infection  to  occur  in  the  first 
place. 

Finally,  temporary  drainage  of  the  entire  abdominal  cavity 
is  possible  for  a  few  hours  after  it  has  been  opened  for  the 
relief  of  diffuse  or  general  peritonitis.  Adhesions  about  the 
drainage  material  shut  off  the  general  peritoneum  within  a 
short  time,  but  the  immediate  relief  of  intra-abdominal  tension 
lessens  septic  absorption  and  may  turn  the  tide  in  the  patient's 
favor. 

Pelvic  drainage  may  be  established  through  the  anterior 
abdominal  wall  or  through  the  posterior  vaginal  fornix. 

In  a  general  way  and  for  several  reasons  that  route  should  be 
chosen  which  traverses  the  least  free,  uncontaminated,  unin- 
fected, peritoneal  surface — first,  that  the  material  to  be  re- 
moved shall  reach  its  exit  most  quickly  and  easily;  second,  that 
it  shall  not  infect  clean  surfaces;  and  third,  that  possible 
adhesions  between  free  coils  of  intestine  may  be  avoided.  It 
is  plain  that  pelvic  abscesses  will  be  drained  by  an  incision 
through  the  vaginal  fornix,  and  most  ovarian  abscesses  in  the 
same  manner.  An  abscess  in  an  ovary  which  is  adherent  at 
or  near  the  pelvic  brim  will,  however,  be  drained  through  the 
anterior  abdominal  wall.  Prophylactic  drainage,  about  an 
infected  area  or  an  injured  intestine,  must  be  so  arranged  as  to 
fulfill  the  indication  of  being  led  out  through  the  nearest 
portion  of  the  abdominal  parieties,  and  practically  all  pelvic 
drains  will  thus  pass  through  the  recto-uterine  excavation 
into  the  vaginal  canal.  A  badly  infected  or  freely  oozing 
surface  in  the  pelvis  can  be  entirely  separated  from  the  general 
abdominal  cavity  by  a  gauze  cofferdam,  upon  the  superior 
surface  of  which  the  sigmoid  colon  rests.  The  gauze  composing 
the  cofferdam  is  led  into  the  vagina  by  posterior  colpotomy 


596  GYNECOLOGIC    SURGERY 

after   the   abdominal  incision  is   closed,   as   described  under 
salpingectomy. 

The  fear  of  contamination  from  the  vagina  is  entirely  un- 
founded providing  every  case  of  pelvic  disease  submitted  to 
abdominal  incision  is  at  the  same  time  prepared  for  possible 
vaginal  section. 

Whenever  possible  a  drain  should  have  the  pelvic  wall  for 
one  of  its  boundaries  rather  than  be  surrounded  by  free  coils  of 
intestine. 

There  has  been  much  unnecessary  discussion  as  to  the  relative 
value  of  tube  and  gauze  drains,  and  the  statement  is  frequently 
made  that  gauze  does  not  drain  but  that  tubes  do.  In  order 
to  decide  upon  the  proper  form  of  drain  for  an  individual  case, 
it  is  necessary  to  determine  what  is  required  of  this  particular 
drain.  In  one  instance  all  that  is  desired  may  be  an  opening 
in  the  parietes  for  a  few  days,  so  that  possible  accumulations 
may  have  a  line  of  least  resistance  through  which  to  escape. 
For  this  purpose  a  small  tube,  gauze  wick,  or  cigarette  drain 
are  each  efficacious  and  the  selection  is  a  matter  of  convenience. 
In  another  case  it  may  be  desired  to  empty  an  abdomen  of 
fluid  under  tension,  and  to  continue  the  drainage  as  long  as 
possible.  In  such  an  event  a  large  exit  is  required  with  as 
few  adhesions  as  possible  about  the  drain  tract,  and  an  open 
incision  without  drainage  material  may  be  the  method  of  choice. 
If  something  is  required  to  keep  the  exit  patent  a  large  rubber 
tube  would  be  selected,  as  it  stimulates  the  formation  of  ad- 
hesions less  rapidly  than  does  gauze.  Gauze  cannot  be  ex- 
pected to  drain  feces,  solid  particles  of  loose  exudate,  sloughs, 
or  thick  pus,  but  gauze  may  well  be  used  to  protect  the  peri- 
toneum about  a  focus  containing  such  material  while  a  large 
tube  gives  exit  to  its  solid  or  semi-solid  contents.  Gauze  is 
perfectly  satisfactory  for  draining  serous,  sero-purulent,  or 
bloody  fluid,  providing  it  is  fluffed  into  place  instead  of  being 
packed  and  if  it  does  not  fill  the  channel  of  exit  through  the 
parietes.     The  cigarette  drain  operates  by  capillarity  only  and 


DRESSINGS  597 

it  often  acts  as  a  stopper  rather  than  a  drain  because  this  is 
overlooked.  The  discomfort  attending  the  removal  of  any 
form  of  gauze  drain  can  be  minimized  by  enclosing  in  rubber 
that  portion  of  it  which  runs  through  the  incision.  Every 
gauze  drain  should  have  its  strength  tested  before  its  in- 
troduction. Re-opening  the  abdomen  has  been  necessitated 
more  than  once  because  the  gauze  had  been  rotted  by  over- 
sterilization  and  tore  into  shreds  during  its  removal. 

Soft  rubber  tubes  should  be  used  in  the  abdomen  in  preference 
to  glass,  hard  rubber,  aluminum,  or  other  hard  material,  as 
the  latter  may  cause  fecal  fistula  by  pressure  upon  the  intestine. 

The  time  for  the  removal  of  a  drain  is  dependent  upon  the 
purpose  for  which  it  was  employed.  A  small  prophylactic 
drain  can  be  taken  out  as  soon  as  it  becomes  apparent  that  it 
is  no  longer  needed.  Tubes  which  drain  pus  foci  should  be 
removed  as  soon  as  the  discharge  is  reduced  to  an  amount  for 
which  the  drain  tract  itself  is  responsible.  Large  gauze  coffer- 
dams should  be  allowed  to  remain  until  they  are  loose,  as  their 
early  removal  is  attended  by  much  discomfort  and  considerable 
danger  from  the  rupture  of  adhesions.  This  sometimes  re- 
quires a  week  or  lo  days,  but  no  danger  is  to  be  apprehended 
from  their  retention  unless  they  become  foul,  which  they  will 
not  do  if  the  gauze  is  iodoformized. 

DRESSINGS 

The  primary  objects  of  a  dressing  are  to  protect  the  wound 
from  contamination,  and  to  keep  the  wound  dry  by  the  absorp- 
tion of  discharge.  Incidentally  a  certain  amount  of  support  is 
afforded  by  the  adhesive  straps  and  bandages  which  retain  the 
dressings  in  position. 

Dressings  to  the  vulva  are  appKed  immediately  at  the  close 
of  operation.  They  should  consist  of  Hghtly  fluffed  loose  gauze 
covered  by  a  large  sterile  pad  containing  absorbent  cotton,  the 
whole  being  kept  in  place  by  a  T-bandage.     The  coarser  the 


598 


GYNECOLOGIC   SURGERY 


mesh  and  the  more  loosely  the  gauze  is  applied,  the  more  rapidly 
are  the  vaginal  secretions  absorbed.  Capillary  drainage  from 
the  recto-uterine  excavation  into  the  external  dressing  is  pro- 
vided by  gauze  loosely  packed  into  the  vagina,  its  upper  end  in 
contact  with  the  abdominal  drain,  its  lower  with  the  external 
dressings.  Abdominal  dressings  are  usually  very  simple. 
The  wound  is  covered  with  dry  sterile  gauze  and  the  gauze  by 
a  pad  containing  absorbent  cotton,  all  being  held  in  place  by 
taped  adhesive  plaster  and  covered  with  a  many-tailed  bandage 
or  simple  swathe. 


jfek 

■r 

Sh&i, 

[ 

0^y 

^^^prr^"^ 

\ 

^          Im^ 

.A 

mk 

f 

— ^^-p  T~^^ 

H 

i< 

■N^^^jJ^^PIr 

ll 

Fig.  268. — Abdominal  dressing  held  by  taped  adhesive. 

plastered  by  an  air-tight  roof. 


The  dressing  is  not 


Abdominal  dressings  should  not  be  so  plastered  with  ad- 
hesive as  to  make  an  impermeable  covering  and  prevent  the 
free  circulation  of  air.  Such  a  roof  defeats  one  of  the  prime 
objects  of  a  dressing  by  preventing  evaporation  and  keeping 
the  wound  surface  moist.  Short  straps  of  adhesive,  attached 
beyond  the  dressings  and  tied  over  them  by  tapes,  are  neat,  can 
be  untied  when  the  dressings  are  changed,  and  are  economical 
as  well.  One  long  strap  running  from  the  trochanters  across 
the  pubes  may  be  necessary  if  the  incision  extends  very  low. 
The  abdominal  bandage  can  be  kept  from  rolling  up  by  a  short 
T  which  is  fastened  to  its  lower  edge  front  and  back,  the  vulva 


DRESSINGS  599 

being  protected  from  chafing  by  a  small  pad.  Drained  wounds, 
especially  when  free  discharge  is  anticipated,  should  have  an 
abundance  of  dressings  appHed  in  the  first  instance,  so  that  the 
patient  is  not  disturbed  during  recovery  from  the  anaesthetic. 
The  time  and  manner  of  changing  dressings  are  of  great  im- 
portance. Dressings  about  the  vulva  should  be  changed  after 
each  urination  and  defecation,  more  frequently  if  saturated. 
Such  dressing  is  commonly  done  by  the  nurse  and  as  a  conse- 
quence the  patient  is  frequently  the  victim  of  poor  technique, 
nurses  of  good  training  and  masters  of  technique  apparently 
finding  it  difficult  to  appreciate  the  necessity  for  the  same  aseptic 
attention  to  the  vulvar  wound  as  to  any  other. 

The  soiled  dressing  is  removed  with  sterile  instruments — 
never  mth  the  fingers — and  the  fresh  one  applied  in  the  same 
manner  after  the  vulva  has  been  cleansed  by  irrigating  with 
sterile  water,  saline,  or  boric  solution,  the  irrigating  fluid  being 
poured  directly  from  a  sterile  graduate  or  pitcher. 

Re-dressing  of  clean  abdominal  wounds  is  not  necessary  until 
the  sutures  are  removed  unless  the  dressing  is  soiled.  The 
constant  fussing  with  a  clean  abdominal  incision  hazards  its 
aseptic  condition,  and  is  a  source  of  unnecessary  hospital  ex- 
pense. Drained  wounds,  on  the  contrary,  should  be  dressed 
as  often  as  the  dressings  are  saturated,  but  the  wound  itself 
should  be  disturbed  as  little  as  possible. 

Dressing  technique  should  be  as  accurate  as  operative  tech- 
nique although  it  may  be  much  less  complicated.  The  dresser 
should  wear  sterile  gloves  in  dressing  drained  or  infected  wounds 
unless  he  is  sufficiently  skillful  to  avoid  hand  contact  with  any  of 
the  soiled  surfaces,  and  whether  gloves  are  worn  or  not  the  hands 
should  be  carefully  scrubbed  and  dried  with  a  sterile  towel. 
The  nurse  turns  back  the  bed  coverings,  unfastens  and  lays 
back  the  bandage  and  unties  the  taped  adhesive,  after  which 
the  dresser  lays  sterile  towels  about  the  area  and  removes  the 
soiled  dressing  with  sterile  forceps.  Dried  blood  and  serum 
should  not  be  removed  from  the  wound  until  the  surface  beneath 


6oO  GYNvECOLOGIC   SURGERY 

is  entirely  healed,  for  both  act  as  efficient  protectives.  It  is 
rare  indeed  that  the  abdominal  surface  or  wound  edges  need 
to  be  washed  or  otherwise  touched  with  any  watery  solution, 
and  the  habitual  use  of  weak  bichloride  solutions  for  this  pur- 
pose is  a  delusion  perpetuated  largely  by  thoughtlessness. 
In  the  strength  commonly  employed  these  are  not  germicidal 
unless  appHed  for  hours,  and  their  habitual  use  tends  to  further  a 
sense  of  security  which  is  by  no  means  justified.  Aside  from  this, 
the  solution  bowls  in  common  use  about  the  wards  are  sure  to 
be  contaminated  sooner  or  later  and  convey  infection  to  a 
clean  wound. 

Ten  to  20  cc.  of  alcohol  in  a  small  sterile  medicine  glass 
furnishes  all  the  ^'solution"  needed  to  cleanse  the  skin  about 
the  ordinary  abdominal  incision,  and  at  least  it  is  always  sterile. 
Clean  gauze  is  picked  up  with  the  forceps  from  the  sterile 
draped  tray  which  holds  it,  fluffed  loosely  on  the  wound,  and 
covered  with  pads  as  in  the  original  dressing,  after  which  the 
tapes  are  tied  and  the  bandage  adjusted  by  the  nurse. 

AFTER-CARE 

Many  fine  operators  achieve  but  mediocre  results,  either 
because  of  their  inefficiency  and  lack  of  knowledge  in  the  after- 
care of  their  patients,  or  because  their  indifference  to  anything 
beyond  the  mechanical  completion  of  an  operation  leads  them 
to  delegate  the  after-care  to  inexperienced  internes.  The  first 
subject  to  which  a  surgical  interne  should  turn  his  attention  is 
the  pre-operative  and  post-operative  medical  aspects  of  surgical 
cases.  Instead  of  this  he  is  more  likely  to  be  intensely  inter- 
ested in  the  glamor  and  eclat  of  the  operating  room,  to  the 
detriment  both  of  his  patients  and  himself. 

Post-operative  care  begins  the  moment  the  dressings  are 
applied  and  the  patient  removed  from  the  table.  At  this  time 
she  should  be  warmly  wrapped  in  a  woolen  blanket  to  prevent 
chilling,  and  be  accompanied  to  her  room  by  a  competent  in- 


AFTER-CARE  6oi 

terne  who  will  see  that  the  head  is  turned  to  one  side  to  prevent 
the  inhalation  of  mucus  or  regurgitated  stomach  contents. 
If  necessary  the  jaw  should  be  kept  forward  to  keep  the  tongue 
from  falling  back  into  the  pharynx  and  covering  the  glottis. 

From  the  time  the  patient  is  returned  to  bed  until  she  is 
completely  conscious  she  should  not  be  left  alone  for  an  instant. 
If  there  is  any  appreciable  shock  she  should  be  kept  between 
blankets  and  have  hot  pads  or  hot- water  bags  applied  outside 
the  blankets.  If  hot-water  bags  are  used  they  must  be  ab- 
solutely secure  as  concerns  leakage  and  never  be  so  hot  as  to 
burn.  While  this  may  seem  to  be  a  nursing  detail,  it  is  one  of 
those  things  for  which  the  patient,  if  not  the  courts,  will  hold 
the  surgeon  liable  if  its  violation  results  in  a  nasty  burn.  The 
foot  of  the  bed  should  be  moderately  elevated  unless  the  ab- 
domen is  septic;  in  this  event  the  head  of  the  bed  should  be  ele- 
vated as  soon  as  the  condition  of  the  pulse  justifies  it.  Moderate 
elevation  of  the  foot  of  the  bed  assists  in  checking  oozing  from 
the  pelvis,  lessens  pain  by  lowering  the  blood  pressure  in  the 
elevated  portion,  and  lessens  the  risk  of  aspiration  of  stomach 
contents  during  recovery  from  the  anaesthetic.  The  room 
should  be  well  aired,  but  not  cold  or  drafty  as  much  harm  is 
done  by  the  academic  conception  that  the  patient  needs  fresh 
air.  While  fresh  air  is  desirable,  a  blast  of  cold  air  from  an  open 
window  is  fairly  certain  to  result  in  disaster  if  directed  upon  a 
perspiring  patient  with  lowered  resistance,  whose  nasal  and 
bronchial  mucosa  are  harboring  pneumococci.  So  also  as 
regards  the  patient's  clothing  during  convalescence.  Many 
delicate  women,  who  have  been  coddled  all  their  Hves,  must 
undergo  operation,  as  must  others  who  have  never  slept  in 
anything  lighter  than  a  set  of  woolens.  Although  it  may  be 
fine  hygienic  discipline,  it  is  not  good  sense  to  subject  either 
class  to  the  cold  air  cure  when  dressled  only  in  a  light  surgery 
jacket. 

Most  patients  are  more  comfortable  if  they  remain  quietly 
in  the  dorsal  position  without  too  much  rolling  from  side  to 


6o2  GYNECOLOGIC    SURGERY 

side.  If  the  position  becomes  irksome  they  can  be  gently  turned 
to  one  side  and  propped  there  with  pillows.  After  one  or  two 
days  any  position  may  be  assumed  that  the  patient  finds 
comfortable. 

The  lips  should  be  moistened  frequently  with  hot  water. 
Cold  water  and  ice  are  craved,  but  they  inevitably  produce 
more  dryness  of  the  mouth  by  checking  the  natural  secretion. 
The  stomach  should  be  kept  empty  until  the  ordinary  ether 
nausea  is  past.  If  nitrous  oxide  has  been  the  anaesthetic, 
the  nausea  may  not  be  marked,  but  there  is  almost  always 
some  nausea  after  an  abdominal  operation  no  matter  what  the 
anaesthetic.  If  nausea  persists  more  than  24  hours,  a  half  pint 
of  warm  water  may  be  given  at  one  time.  This  is  sometimes 
retained  and  at  others  rejected,  but  it  washes  out  the  stomach 
by  its  return.  Cold  water  and  ice  usually  lead  to  persistent 
nausea  and  vomiting  although  they  are  gratifying  at  the  time, 
but  the  patient  is  more  nearly  normal  at  an  earlier  date  if  they 
are  withheld.  Great  thirst  can  be  met  by  the  administration 
of  water  by  the  drop  method  per  rectum. 

The  temperature  should  be  taken  per  rectum  after  all 
abdominal  operations,  and  it  should  be  recorded  every  four 
hours  during  the  first  three  days.  Usually  it  is  between  97.5° 
and  98°  for  the  first  few  hours  and  then  rebounds  to  between 
100°  and  ioi.5°F.  Temperatures  considerably  higher  than 
this  may  be  noted  in  patients  who  are  making  a  perfectly  satis- 
factory convalescence.  The  pulse  should  be  recorded  every 
hour,  and  after  two  or  three  days  every  four  to  six  hours. 
Marked  differences  in  the  pulse  rate  are  observed  in  different 
individuals.  A  pulse  as  low  as  60,  or  as  high  as  120,  need  cause 
no  concern  if  its  quality  and  rhythm  are  good.  A  very  soft  pulse 
during  the  first  few  hours  is  more  significant  than  its  rate  alone, 
and  demands  investigation. 

An  uncomfortably  fast  pulse,  without  adequate  explanation 
in  the  abdominal  condition,  is  often  due  to  hyperthyroidism 
and  is  controlled  by  an  ice-cap  to  the  neck  and  another  over  the 


A^TER-CARE  603 

heart.  The  respiration  should  be  taken  as  carefully  as  the 
pulse  but  needs  recording  less  frequently;  sighing  respiration  and 
pallor  shortly  after  an  operation  mean  danger,  and  a  respira- 
tion rate  which  exceeds  30  per  minute  usually  signifies  the  onset 
of  some  pulmonary  compHcation. 

After  all  the  instruments  of  precision  have  been  used,  how- 
ever, one  good  unbiased  look  at  the  patient's  face  will  tell  the 
trained  observer  more  than  he  can  gather  from  the  bedside 
records. 

Very  little  or  no  medication  is  required  during  the  first 
two  or  three  days  after  the  ordinary  gynaecologic  operation, 
excepting  such  as  may  be  needed  for  pain.  Morphine  hypo- 
dermatically  may  be  used  as  necessary  unless  there  is  a  distinct 
contra-indication.  Such  a  contra-indication  is  found  in  the 
combination  of  severe  paroxysmal  pain  with  obstinate  consti- 
pation and  vomiting  of  intestinal  contents;  under  virtually  no 
other  circumstances  is  it  necessary  to  withhold  narcotics  after 
operation,  the  fussiness  over  the  presumed  effect  on  the  kidneys 
and  intestinal  tract  being  wholly  without  a  reasonable  basis  of 
fact.  Morphine  does,  however,  nauseate  a  considerable  number 
to  whom  it  is  administered,  and  it  should  be  given  only  for  real 
physical  discomfort.  '' Nervousness"  is  readily  controlled 
by  large  doses  of  bromide  per  rectum. 

The  bladder  needs  careful  attention  during  the  first  48 
to  72  hours.  After  any  operation,  in  which  the  ureter  or  bladder 
might  have  been  injured  unwittingly,  the  catheter  should  be 
passed  before  the  patient  leaves  the  surgery.  Clear  urine  which 
is  not  blood-stained  gives  assurance  that  such  an  accident  has 
not  occurred.  Over-distension  after  operations  for  cystocele 
and  retrodisplacements  may  entirely  nullify  the  operative 
result.  On  the  contrary,  frequent  catheterization  must  be 
avoided  and  if  the  patient  can  void  naturally  she  should 
be  allowed  to  do  so.  When  spontaneous  urination  is  impossible 
the  catheter  should  be  used  just  often  enough  to  prevent  over- 
distension, which  never  takes  place  in  less  than  8  hours  and 


6o4  GYNyECOLOGIC    SURGERY 

is  not  likely  to  within  the  first  24.  The  secretion  of  urine 
during  the  first  24  hours  after  an  abdominal  operation  rarely 
exceeds  500  cc.  and  may  not  be  more  than  one-half  this  amount. 
Less  than  250  cc.  in  the  first  24  hours  demands  investigation. 
From  this  time  on  the  quantity  gradually  becomes  normal,  and 
the  bladder  should  be  evacuated  three  or  four  times  daily 
which  is  often  enough  to  prevent  discomfort. 

In  the  event  that  injury  to  the  bladder  has  occurred,  it 
should  be  kept  empty  by  a  retention  catheter  until  firm  ad- 
hesions have  taken  place,  when  frequent  catheterization  is 
taken  up  in  its  stead. 

When  for  any  reason  frequent  or  long-continued  catheteriza- 
tion is  required,  hexamethylenamine  should  be  given  in  10- 
grain  doses  two  or  three  times  daily,  and  the  bladder  may  be 
irrigated  once  daily  while  the  catheter  is  in  place.  It  is  the 
introduction  of  the  catheter  which  causes  cystitis  and  not  its 
presence  in  the  bladder. 

That  attention  to  the  bowels  which  is  necessary  in  the 
after-care  of  patients  who  have  had  plastic  operations  upon  the 
perineum  has  been  given  in  the  section  devoted  to  that  subject. 

No  attention  need  be  paid  to  the  bowels  for  the  first  48 
hours  after  abdominal  operations  unless  the  pelvic  colon  or 
rectum  have  been  injured.  In  this  event  the  anus  should 
be  dilated  before  the  patient  leaves  the  table,  and  a  short 
rectal  nozzle  inserted  and  allowed  to  remain  for  some  days  in 
order  to  obviate  distension  of  the  injured  portion  and  prevent 
tension  upon  the  sutures  inserted  for  its  repair. 

If  the  gut  has  not  been  injured,  an  enema  of  salts  and  glyc- 
erin aa  5i)  soap  suds  Oi  is  administered  on  the  third  day, 
and  this  is  usually  followed  by  the  expulsion  of  flatus.  If 
no  flatus  is  expelled  this  enema  may  be  followed  by  a  larger 
one  of  soap  suds.  InabiHty  to  expel  a  large  enema  should  lead 
to  the  introduction  of  the  rectal  tube  rather  than  to  repeti- 
tion of  the  enema.  If  the  second  enema  is  not  effectual,  but 
there  is  neither   vomiting  nor  marked   distension,  efforts   at 


AFTER-CARE  605 

moving  the  bowels  are  better  discontinued  until  the  next  day 
when  a  repetition  of  the  above  program  will  produce  satisfac- 
tory results.  If,  however,  there  is  distension  with  nausea  and 
vomiting,  an  enema  of  an  ounce  of  alum  in  a  pint  of  plain 
water  may  be  given,  and  when  this  is  ineffectual  the  rectum 
and  lower  colon  should  be  washed  out  with  warm  soap  suds 
given  through  a  funnel  attached  to  the  rectal  tube.  This  is 
siphoned  off  when  the  patient  becomes  uncomfortable,  and  is 
repeated  until  several  quarts  have  been  used.  It  is  rare  that 
this  fails  to  secure  the  desired  result  in  the  absence  of  organic 
obstruction  or  paralytic  ileus. 

If  the  bowel  has  been  injured,  small  enemas  only  should  be 
given  and  they  should  be  introduced  without  pressure.  Cathar- 
tics are  contra-indicated  if  the  bowels  fail  to  move  by  the  use  of 
enemas.  Obstruction  cannot  be  overcome  but  on  the  contrary 
is  made  worse  by  cathartics,  and  in  the  absence  of  obstruction 
the  bowels  sooner  or  later  will  respond  to  enemas. 

Bombarding  a  patient  with  calomel  as  soon  as  she  can  swallow, 
in  an  effort  to  obtain  the  early  passage  of  flatus,  does  the  pa- 
tient no  good  and  is  very  disagreeable.  This  practice  has 
no  better  basis  than  the  nervous  apprehension  of  the  operator 
that  obstruction  or  peritonitis  might  be  present,  but  surely  are 
not  if  the  bowels  move. 

No  food  should  go  into  the  stomach  until  the  digestive  tract 
is  ready  for  it.  In  patients  who  have  had  plastic  operations 
this  may  be  on  the  second  day.  After  abdominal  operations  a 
clear  soup  and  orange  or  lemon  albumen  may  be  rehshed  by 
this  time,  but  neither  soHd  food  nor  milk  should  be  given  until 
the  disposition  to  tympany  has  disappeared  and  the  bowels 
move  with  no  more  difl&culty  than  would  be  expected  in  a 
patient  who  is  confined  to  bed. 

It  cannot  be  stated  too  imperatively  that  during  the  first 
few  days  after  a  serious  abdominal  operation  the  patient  needs 
all  her  strength  for  recuperation,  and  that  unnecessary  visit- 
ing, bathing,  and  hair  dressing  should  be  interdicted.     Every 


6o6  GYNECOLOGIC    SURGERY 

emotion  and  every  mental  effort  requires  an  expenditure  of 
energy  which  is  better  conserved  than  wasted. 

The  patient  should  be  well  past  any  actual  operative  or 
anaesthetic  discomfort  in  72  hours,  and  the  actual  surgical  con- 
valescence may  then  be  said  to  begin. 

After  this  time  the  temperature,  pulse,  and  respiration 
should  be  normal  or  approximately  so,  and  need  be  taken  but 
three  times  in  24  hours. 

Ordinarily,  too,  the  bladder  is  evacuated  spontaneously  and 
the  quantity  of  urine  is  nearly  normal.  The  bowels  usually 
continue  to  need  some  attention  because  of  the  restricted  diet 
and  lack  of  exercise,  and  a  daily  enema  or  one  every  second  day, 
alternating  with  a  few  grains  of  cascara,  a  small  dose  of  mag- 
nesia, or  2  to  4  drams  of  liquid  albolene,  suffice  to  keep 
them  in  order.  The  diet  should  be  increased  as  the  patient's 
appetite  dictates;  usually  she  is  on  the  regular  house  diet  at 
the  expiration  of  a  week,  and  earlier  than  this  if  the  operation 
has  been  of  a  minor  character. 

A  daily  bath,  with  thorough  rubbing  of  the  back,  arms  and 
legs,  promotes  comfort  and  is  a  fair  substitute  for  the  exercise 
to  which  the  patient  is  accustomed. 

The  time  for' sitting  up  varies  with  the  nature  of  the  opera- 
tion and  the  physical  condition  of  the  patient. 

Patients  with  extensive  plastic  operations  should  remain 
in  bed  for  a  full  two  weeks.  There  is  no  danger  of  their  "  tear- 
ing the  stitches"  at  a  much  earher  date,  but  the  inevitable 
stretching  of  the  parts  begins  as  soon  as  tension  of  the  ab- 
dominal muscles  increases  the  intra-abdominal  pressure.  After 
a  muscle-sphtting  incision  through  the  anterior  abdominal 
wall,  a  patient  might  be  up  within  a  day  or  two  without  risk  to 
the  integrity  of  the  incision,  but  she  would  lose  more  than  she 
gained.  After  a  straight  incision  sufficient  time  should  be 
given  to  obtain  a  fair  degree  of  strength  in  the  wound,  and 
wounds  heal  more  quickly  when  at  rest.  The  fad  for  rushing 
patients  out  of  bed,  as  soon  as  they  can  possibly  sit  erect  with- 


AFTER-CARE  607 

out  fainting,  has  its  basis  in  a  deficient  sense  of  the  relative 
value  of  things.  Most  patients  who  submit  to  an  operation  care 
less  for  the  cost  of  a  few  days  in  the  hospital  than  they  do  for 
a  complete,  satisfactory  recovery,  once  they  have  gone  to  the 
inconvenience  and  expense  of  having  an  operation  performed 
at  all.  No  matter  how  trifling  the  risk  of  hernia,  nor  how 
slight  the  danger  to  hfe  from  secondary  hemorrhage,  there 
is  no  gainsaying  the  fact  that  the  site  of  incision  is  more  com- 
fortable if  no  strain  is  put  upon  it  before  it  is  perfectly  sound. 

Neither  should  patients  leave  the  hospital  until  they  are 
able  to  care  for  themselves  without  inconvenience,  and  in  this 
respect  the  home  faciHties  vary  so  greatly  that  no  set  rule  can 
be  laid  down.  After  the  average  abdominal  operation  a  patient 
should  be  propped  up  in  bed  in  10  or  12  days,  be  out  of  bed  in 
two  weeks,  and  leave  the  hospital  as  soon  after  this  as  the 
circumstances  justify.  The  httle  discipHne  enforced  by  regular 
hospital  rules  is  over  all  too  soon  for  the  greater  number  of 
patients,  whose  whole  welfare,  rather  than  their  wounds  alone, 
should  be  taken  into  consideration. 

Medication  during  this  period,  aside  from  the  occasional 
laxative  mentioned  above,  should  be  employed  according  to  the 
indications.  An  occasional  dose  of  bromide  for  a  wakeful 
patient,  a  bitter  tonic  for  those  whose  appetite  is  deficient,  and 
iron  for  those  who  are  anaemic,  are  of  course  indicated. 

After  dismissal  from  the  hospital  the  patient  should  remain 

under  the  surgeon's  observation  for  a  number  of  weeks,  during 

which  an  occasional  examination  ought  to  be  made  and  the 

findings  noted  on  the  case  history.     This  not  only  serves  the 

object  of  scientific  completeness  of  observation,  but  it  enables 

one  to  orient  himself  as  to  the  efiicacy  of  various  methods  of 

operating  and  acts  as  a  guide  to  future  diagnosis  should  further 

trouble  occur. 

REFERENCES 

OVERLOCK,  S.  B.— Surgical  Catharsis.     N.  York  M.  /.,  1913,  xcvii,  599. 
BOVEE,  J.  "W. — Complete  Sterilization  of  the  Skin  by  Iodine.     Am.  J.  of 
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BECKMAN,  E.  H. — Simple  Method  of  Preparing  the  Skin  for  Surgical  Opera- 
lions.     Interstate  M.  J.,  191 1,  xviii,  7. 
CANNADY. — A  Review  of  the  History  of  the  Iodine  Methods  of  Skin  Sterili- 
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792. 
GROSSICH,  A. — Eine  neue  Sterilisierungsmethode  der  Haut  bei  Operationen. 

Zentralb.f.  Chirurg.,  1908,  xxxv,  1289. 
GROSSICH,  A. — Zu  Meinem  Disinfektionsverfahren  der  Haut  des  Operations- 

feldes  mittels  lodtinktur.     Zentralb.  f.  Chirurg.,  1910,  xxxvii,  737. 
GIBSON. — Disinfection  of  the  Skin  by  Tincture  of  Iodine.     Annals  of  Surg., 

1911,  liii,  106. 
McDonald. — Disinfection  of  the  Hands  and  Abdominal  Skin  before  Operation. 

Surg.,  Gyn.  6*  Obst.,  1915,  xxi,  82. 
AHLFELD. — Der  Kernpunkt  in  der  Frage  von  der  Bedeutung   des  Alkohols 

bei  der  Handedesinfektion.     Zeitsch.  f.  Geb.  und  Gyn.,  1914,  Ixxv,  504. 
LAUBENHEIMER. — Bemerkungen  zu  Kritik  der  Handedesinfektionsmethoden 

von  R.  Schaeflfer.     Zeits.  f.  Geb.  und  Gyn.,  1912,  Ixxii,  645. 
KELLY,  HOWARD  A.— Hand  Disinfection.     Atn.  J.  Obst.,  1891,  xxiv,  1414. 
BARTLETT.— A  Simple  Heat  Method  of  Sterilizing  and  Storing  Catgut.     Surg., 

Gyn.  &"  Obst.,  1914,  xviii,  633. 
MILLER,  G.  BROWN.— The  Sterilization  of  Catgut.     Johns  Hopkins  Hosp. 

Bull.,  1900,  xi,  225. 
SI G WART. — Die  bakteriologische  Kontrolle  der  Asepsis  bei  gynaekologischen 

Laparotomien.     Arch.  f.  Gyn.,   1913,  xcix,   284;  Internal.  Abst.  of  Surg., 

Dec,  1913. 
LECEUE. — Prophylaxie   de  I'infection  peritoneale  op6ratoire  en   gynecologic. 

Ann.  d.  Gyn.  e.d.  Obst.,  1912,  ix,  513;  Internal.  Abst.  Surg.,  Feb.,  1913,  22. 
FINSTERER. — Ueber  die  Bedeutung  der  Anasthesie  fur  den  Verlauf  der  Lapar- 

otomie.     Wien.  klin.  Woch.,  1913,  xxvi,  1560;  Abst.  Internal.  Absl.  Surg., 

Feb.,  1914,  127. 
SKEEL,  R.  E. — The  Selection  of  the  Anaesthetic  for  Abdominal  and  Pelvic 

Surgery.     Am.  J.  Obst.,  1913,  Ixvii,  103. 
BEVAN,  MOORE,  GATCH,  MELTZER,  HENDERSON,  CRILE.— Symposium 

on  Anaesthesia.     Trans.  Am.  Surg.  Assn.,  191 1,  xxix,  177-247. 
McGRATH. — A  Discussion  of  Various  Anaesthetics  and  Methods.     Experimental 

Observations.     /.  A.  M.  A.,  1913,  Ixi,  1516. 
MAHONEY,  ALLEN,  MANDELL,  QUINBY,  EHRENFRIED.— Symposium  on 

Anaesthesia.     Boston  M.  6*  S.  J.,  191 1,  clxv,  587. 
SCHLIMPERT. — Studien  zur  Narkose  in  der  Gynakologie.     Arch.  f.  Gyn., 

1914,  cii,  207. 
HERB. — The  Selection  of  an  Anaesthetic.     Surg.,  Gyn.  &*  OhsL,  1912,  xv,  223. 
KELLY,   R.   E. — Anaesthetic   Fatalities.     Liverpool  Medico-Chir.  Jour.,    1913, 

xxxiii,  154. 
BUXTON,  DUDLEY  W.— Dangers  and  After-effects  of  Anaesthesia.     Clinical 

Jour.,  191 2,  xl,  33. 


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SKJEEL,  R.  E. — The  Choice  of  Anaesthetics  from  the  Standpoint  of  the  Surgeon, 

etc,     Ohio  Stale  Med.  /.,  191 2,  viii,  480. 
BRUNNER. — Ueber   die   Erfolge   mit  Lumbalanaesthesia   bie   der   Operation. 

Monats.f.  Geb.  tmd  Gyn.,  1907,  xxvi,  701. 
BABCOCK. — The  Dangers  and  Disadvantages  of  Spinal  Anaesthesia.     N.  York 

M,  J.,  1913,  xcviii,  897. 
BABCOCK. — Spinal  Anaesthesia.     Surg.,  Gyn.  6°  Obst.,  191 2,  xv,  606. 
BABCOCK. — Spinal  Anaesthesia  in  Gynaecology,   Obstetrics,   and  Abdominal 

Surgery.     /.  A.  M.  A.,  1913,  Ixi,  1358. 
BAILEY,  F.  W. — ^ther:  The  Technique   of  Its   Administration.     Liverpool 

Medico-Chir.  Jour.,  1913,  xxxiii,  142. 
BERKELEY,  C.  AND  BONNEY,  V.— A  Text-book  of   Gynecological  Surgery. 

London,  191 1. 
CRILE,  G.  W.  AND  LOWER,  WM.  E.— Anoci-association.     Philadelphia,  1914. 
GWATHMEY,  JAMES  T.— Anesthesia.     New  York,  1914. 
BUXTON,  DUDLEY  W.— Anaesthetics,  Their  Uses  and  Administration.     (5  th 

edition),  London,  1914. 
KIELLY,  H.  A. — Operative  Gynecology.     (2nd  edition).  New  York,  1906. 
HARTMAN,  H. — Gynecological  Operations,  Including  Non-operative  Treatment 

and  Minor  Gynecology.     Philadelphia,  19 13. 
KELLY,   H.  A.  AND  NOBLE,  C.  P.— Gynecology    and  Abdominal  Surgery. 

Philadelphia,  1907. 
PRYOR,  W.  R. — Treatment  of  Pelvic  Inflammation  Through  Vagina. 
PARKER,  C.  B. — Clinical  Observations  upon  the  Administration  of  Nitrous 

Oxide  and  Oxygen  for  General  Surgical  Anaesthesia.     Cleve.  M.  J.,  1909, 

viii,  389. 
COTTON  F.  J.  AND  BOOTHBY,  W.  M.— Nitrous  Oxide  and  Oxygen  Anses- 

thesia.     Surg.,  Gyn.  b°  Obst.,  191 2,  xiv,  195. 
ALLEN,    F. — Nitrous    Oxide    and    Oxygen    Anaesthesia    in    Major    Surgery. 

/.  A.  M.  A.,  1912,  Iviii,  395. 
COBURN,  R.  C. — The  Advantages  of  Nitrous  Oxid-oxygen  Anaesthesia  Especi- 
ally in  Connection  with  Ultimate  Recovery.     J.  A.  M.  A.,  191 1,  Ivi,  499. 
TETER,  C.  K. — The  Limitations  of  Nitrous  Oxide  with  Oxygen  as  a  General 

Anaesthetic.     /.  A.  M:  A.,  191 2,  lix,  1849. 
TETER,  C.  K. — Requirements  and  Limitations  of  Nitrous  Oxide  and  Oxygen 

as  a  General  Anaesthetic  in  Major  Surgery.     Lancet  Clin.,  191 1,  cv,  70. 
CRILE,  G.  W. — Nitrous  Oxide  Anaesthesia  and  a  Note  on  Anoci-association. 

A  New  Principle  in  Operative  Surgery.     Surg.,  Gyn.  &'  Obst.,  191 1,  xiii,  170. 
CRILE,    G.   W. — Anaesthesia    and    Anoci-association.     Surg.,   Gyn.    6"   Obst., 

1913,  xvi,  627. 
HIRST. — The  Needlessness  of  Combined  General  and  Local  Anaesthesia,  etc. 

Am.  J.  Obst.,  1914,  Ixix,  617. 
FARR. — xVbdominal  Incisions.    Journal-Lancet,  191 2,  xxxii,  561. 
BORDEN,  W.  C— A  History  of  Surgical  Haemostasis.     N.  York  M.  J.,  191 2, 

xcvi,  373,  430. 

39 


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WETHERELL,  H.  G.— Surgical  Haemostasis.     N.  York  M.  J.,  1910,  xci,  631. 
MONTGOMERY,  E.  E.— The  Consideration  of  the  Methods  of  Haemostasis 

in  Abdominal  Surgery,     Am  Gyn.  &f  Obst.  J .,  1900,  xvii,  301. 
DAVENPORT,  F.  H.— The  Use  of  the  Angiotribe.     Boston  M.  dr  S.  J.,  1910, 

cxliii,  4. 
BORCHGREVINK,  O.— Surgical  Knots.     Surg.,  Gyn.  &=  ObsL,  1910,  x,  530. 
MONKS,  G.  H. — Tying  the  Knots  of  Ligatures  and  Sutures  with  One  Hand. 

Annals  of  Surg.,  1912,  Ivi,  780. 
CLARK,  J.  G. — A  Critical  Review  of  Seventeen  Hundred  Cases  from  the  Stand- 
point of  Intraperitoneal  Drainage.     Am.  J.  Obst.,  1897,  xxxv,  481. 
DANDY  AND  ROWNTREE.— Peritoneal  and  Pleural  Absorption  with  Reference 

to  the  Postural  Treatment.     Annals  of  Surg.,  1914,  lix,  587. 
RHOADS,  J.  N. — Some  Experimental  Demonstrations  in  Surgical  Drainage. 

Am.  J.  of  Surg.,  1911,  xxv,  348. 
YATES,  J.  L. — An  Experimental  Study  of  the  Local  Effects  of  Peritoneal  Drain- 
age.    Surg.,  Gyn.  &'  Obst.,  1905,  i,  473. 
SCHLLMPERT.— Ueber  den  Wert  der  Bauchhohlendrainage.     Zeiis.  f.  Geb. 

undGyn.,  1912,  Ixxii,  61. 
ALCOCK,  REGINALD  .—Iodine  as  the  Sole  Dressing  for  Operative  Wounds. 

Brit.  M.  J.,  191 2,  i,  233. 
BALFOUR. — The  Care  of  Surgical  Patients.     Med.  Record,  1914,  Ixxxv,  378 
WALLACE,   A.   J. — Preparation    for    and  After-treatment   of    Gynaecological 

Coeliotomies.    Practitioner,  19 10,  Ixxiv,  501. 
CUMSTON,  C.  G. — Traumatic  and  Post-operative  Retention  of  Urine.     Am.  J. 

Urol.,  1910,  vi,  551. 
JACOBSON  AND  KELLER.— Post-operative  Retention  of  Urine  and  Cystitis. 

/.  A.  M.  A.,  1911,  Ivii,  1980. 
WALKER. — A  Further  Protest  Against  the  Routine  Use  of  Purgatives.     Trans. 

Am.  Assn.  Obst.  b'  Gyn.,  191 1,  xxiv,  17. 
WELLS,  B.  H. — The  Post-operative  Treatment  of  Abdominal  Section  for  Pelvic 

Disease  with  Especial  Reference  to  Early  Rising,  etc.     Trans.  Am.  Gyn. 

Soc,  1910,  xxxv,  450. 
WALLACE,  A.  J.— A  Note  on  Early  Rising  after  Coeliotomy.     /.  Obst.  6*  Gyn., 

lirit.  Emp.,  1912,  xxi,  279. 
KELLY,   H.  A. — Getting  up  Early  after  Grave  Surgical  Operations.     Surg., 

Gyn.  b"  Obst.,  191 1,  xiii,  78. 


CHAPTER  XX 

POST-OPERATIVE  COMPLICATIONS  AND  SEQUELS 

Shock. — Unless  operative  hemorrhage  has  been  severe  or  the 
patient  was  in  serious  condition  before  operation,  shock  is  an 
unusual  phenomenon  in  pelvic  surgery.  While  the  clinical 
manifestations  of  shock  are  unmistakable,  its  exact  nature  has 
not  been  determined  beyond  a  reasonable  doubt.  The  S3nnp- 
toms  are  usually  manifested  before  the  patient  leaves  the  table, 
and  consist  of  a  rapid  soft  pulse,  profuse  perspiration,  cold 
extremities,  lowered  blood  pressure,  and  sHght  cyanosis.  Added 
to  these  is  a  markedly  sub-normal  temperature.  After  a  patient 
in  severe  shock  has  recovered  consciousness  she  often  has  a 
clear  conception  of  the  seriousness  of  her  condition  but  is 
without  any  great  anxiety  over  the  probabihty  of  a  fatal  ending. 

Unless  shock  is  plainly  the  result  of  traumatism  plus  operative 
hemorrhage,  its  differentiation  from  post-operative  hemorrhage 
is  easy,  the  air  hunger  of  the  latter  being  conspicuous  by  its 
absence.  On  compressing  a  finger  proximal  to  the  nail,  the 
appearance  of  marked  congestion  distal  to  the  point  of  pressure 
indicates  the  absence  of  hemorrhage,  when  a  condition  of 
profound  systemic  depression  can  be  nothing  but  shock. 

The  treatment  of  shock  must  be  on  an  entirely  empirical 
basis  until  we  understand  its  exact  nature.  The  three  most 
promising  theories  of  shock  are,  the  old  one  of  dilatation  of  the 
vessels  in  the  splanchnic  area  leading  to  cerebral  anaemia, 
Henderson's,  of  over-ventilation  of  the  tissues  with  consequent 
loss  of  the  normal  carbon  dioxide  stimulation  of  the  respiratory 
center,  and  Crile's,  of  traumatic  or  psychic  over-stimulation, 
followed  by  an  exhaustion  of  the  central  nervous  system  making 
itself  especially  felt  in  absence  of  vaso-motor  control.     The 

6ii 


6l2  POST-OPERATIVE    COMPLICATIONS   AND    SEQUELS 

possibility  of  anaphylactic  shock  seems  to  have  been  overlooked 
by  observers,  but  it  cannot  be  disputed,  and  it  may  explain 
some  of  the  unexpected  phenomena  which  follow  the  spilHng 
of  sterile  pus,  cyst  contents,  and  like  protein  material  in  the 
abdominal  cavity. 

Shock  is  more  readily  prevented,  than  treated  after  its  full 
development. 

The  prevention  of  hemorrhage,  thorough  protection  of  ex- 
posed peritoneal  surfaces,  avoidance  of  traction  on  mesenteries 
and  pedicles,  gentle  handhng  of  all  tissue,  and  local  anaesthesia 
of  shock-producing  areas,  in  the  order  named  seem,  to  be  the 
most  important  operative  precautions  in  preventing  and 
minimizing  shock. 

Prolonged  anaisthetization  undoubtedly  contributes  in  no 
small  degree  to  the  production  of  shock  phenomena,  so  that 
time-consuming  unimportant  details  must  sometimes  be  omitted 
in  the  course  of  a  serious  operation,  while  they  might  be  en- 
tirely in  order  in  a  less  dangerous  one.  The  use  of  morphine 
before  and  sometimes  its  repetition  in  rather  heroic  doses  dur- 
ing operation,  is  valuable  in  preventing  the  onset  of  shock. 
Small  doses  of  morphine  in  the  24  hours  preceding  a  grave 
operation  certainly  are  of  value  in  the  prevention  of  unstable 
nervous  equilibrium  brought  about  through  the  influence  of 
the  mind. 

Certain  measures,  which  are  of  unquestioned  value  in  the 
treatment  of  well-developed  shock,  combat  symptoms  that  are 
the  phenomena  of  depression,  and  among  these  the  most  im- 
portant are  the  ones  which  seek  the  restoration  of  body  heat. 
If  the  surface  of  the  body  is  thoroughly  dry,  heat  dissipation 
is  lessened,  and  the  external  appHcation  of  warmth  acts  in  the 
same  manner.  The  patient,  therefore,  should  be  thoroughly 
but  quickly  rubbed  dry  and  wrapped  in  woolen  blankets  to 
prevent  evaporation,  while  hot  pads  or  hot-water  bottles  are 
applied  outside  the  blankets.  The  intravenous  use  of  i  per  cent, 
saline  solution  is  of  great  value,  and  the  subcutaneous  use 


POST-OPERATIVE   SHOCK  613 

of  the  same  solution  is  equally  good  although  less  prompt 
in  its  action.  Hot  saline  per  rectum  by  the  drop  method  may 
be  used  instead  of  the  others  where  the  necessity  is  less  urgent. 
If  there  is  actual  collapse  with  imperceptible  pulse,  the  head 
should  be  lowered  to  prevent  fatal  syncope  and  10  drops  of 
adrenalin  solution  be  added  to  the  intravenous  saline.  Direct 
transfusion  of  blood  combats  shock  in  a  wonderful  manner 
when  hemorrhage  has  been  a  contributing  factor,  but  it  should 
not  be  used  to  the  exclusion  of  the  above  measures  which  can 
be  carried  out  while  the  arrangements  for  transfusion  are  being 
made. 

After  the  full  development  of  shock,  morphine  in  small  doses 
acts  well  in  case  it  has  not  been  used  previously,  but  if  the 
patient  has  been  thoroughly  narcotized  preceding  or  during 
the  operation  it  is  of  doubtful  value. 

Other  drugs  frequently  used  are  strychnine,  alcohol,  atropin, 
and  digitalis.  All  of  them  seem  to  be  useful  at  times,  and  at 
others  to  be  useless  or  actually  harmful. 

Strychnia  is  u'sed  much  too  frequently.  A  single  large  dose 
is  of  apparent  value  in  collapse,  but  short  of  this  condition 
it  does  no  good  whatever.  Digitalis  acts  very  slowly,  but 
Cloetta's  digitoxin  as  dispensed  in  the  solution  known  commer- 
cially as  ^'Digalen,"  can  be  given  intravenously,  and  one 
maximum  dose  of  i  cc.  of  the  solution  sometimes  braces  a 
failing  heart  in  a  remarkable  manner. 

Patients  with  cold  extremities,  who  are  sweating  profusely 
and  seem  to  be  thoroughly  dehydrated,  are  sometimes  benefited 
by  a  single  h3^odermic  of  atropin,  while  the  use  of  alcohol  is 
wholly  a  matter  of  guess  work. 

Post-operative  Hemorrhage. — Hemorrhage  after  operation 
is  of  two  forms,  the  old  time  secondary  hemorrhage  due  to 
sloughing  being  seen  so  rarely  as  to  be  negligible.  The  first 
is  continuous  oozing  from  large  denuded  areas,  the  second  is 
bleeding  from  an  overlooked  or  poorly  tied  vessel. 

Oozing  is  not  dangerous  unless  the  constant  small  blood  loss 


6 14  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELS 

takes  place  in  a  patient  previously  exsanguinated,  when  it 
may  turn  the  scale  against  recovery.  Both  serious  oozing  and 
free  hemorrhage  are  more  likely  to  occur  in  patients  who  were 
operated  upon  in  the  high  Trendelenburg  position,  and  who 
at  the  same  time  suffered  considerable  reduction  of  blood 
pressure.  Oozing  may  seem  to  have  ceased  completely  and 
fairly  large  open  vessels  may  be  overlooked  because  they  do 
not  spurt,  but  hemorrhage  takes  place  after  the  patient  is 
returned  to  bed  with  her  pelvis  lowered. 

The  symptoms  of  serious  post-operative  bleeding  are  plain; 
constant  diminution  in  the  pulse  tension,  usually  but  not  neces- 
sarily with  increase  in  the  rate,  increasing  pallor,  blanching 
of  the  visible  mucous  membranes,  restlessness,  air  hunger  and 
inabihty  to  see  plainly,  all  point  to  bleeding,  and  the  differen- 
tiation from  plain  shock  is  made  by  noting  the  color  under  the 
nail  when  the  return  circulation  is  cut  off  by  pressure  on  the 
dorsum  of  the  finger  just  proximal  to  the  nail.  Quick  increase 
in  color  means  shock;  no  increase  means  hemorrhage.  In 
drained  cases  the  blood  makes  its  appearance  externally  in 
sufficient  quantities  to  render  the  diagnosis  easy.  If  there  is 
real  doubt,  and  the  abdomen  is  closed,  some  stitches  may  be 
removed  or  the  posterior  vaginal  fornix  opened  under  local 
anaesthesia. 

The  character  of  the  operation  will  generally  indicate 
whether  simple  oozing  or  severe  bleeding  is  present.  If  an  old 
pyosalpinx  with  dense  adhesions  has  been  removed  and  all 
vessels  ligated,  but  the  oozing  from  raw  surfaces  was  free  and 
controlled  with  difficulty,  the  probability  is  that  oozing  has 
recurred. 

If  a  huge  fibroid  without  adhesions  has  been  removed,  and 
the  symptoms  above  noted  make  their  appearance  a  few  hours 
later  together  with  very  severe  abdominal  pain,  there  is  no 
doubt  that  a  large  vessel  is  bleeding. 

Treatment. — The  foot  of  the  bed  should  be  elevated  at  once, 
not  so  much  to  prevent  syncope,  which  might  prove  fatal,  but 


POST-OPERATIVE   HEMORRHAGE  615 

is  more  likely  to  be  conservative,  as  to  lower  the  blood  pressure 
in  the  pelvis.  Neither  blood-pressure  raising  nor  vaso-dilating 
drugs  should  be  given  until  the  bleeding  is  under  control.  If 
nothing  more  serious  than  oozing  is  taking  place  this  elevation 
together  with  ice-bags  over  the  pelvis  may  prove  sufficient.  The 
injection  of  alien  serum  hypodermatically  or  direct  blood 
transfusion  may  be  safer  than  re-opening  the  abdomen,  but  if 
things  look  very  serious  the  patient  should  be  transfused  and 
re-operated  simultaneously,  and  the  oozing  surface  tightly 
tamponed.  It  is  needless  to  say  that  such  a  secondary  opera- 
tion must  be  done  speedily  and  with  a  minimum  of  anaesthetic. 
Ether  should  be  given  because  it  is  less  depressing  than  chloro- 
form and  allows  of  more  rapid  operating  with  less  traumatism 
than  does  nitrous  oxide.  After  oozing  is  controlled  by  a 
second  operation  sahne  solution  may  be  given  subcutaneously 
or  intravenously,  but  hot  saline  per  rectum  should  be  avoided 
as  it  is  Kkely  to  start  the  bleeding  anew. 

If  the  bleeding  proceeds  from  a  large  vessel,  nothing  is 
Ukely  to  succeed  short  of  re-opening  the  abdomen  and  clamp- 
ing or  ligating  the  bleeding  point.  This  being  true  the  sooner 
the  secondary  operation  is  begun  the  better.  While  speed  is 
necessary,  the  aseptic  technique  should  be  as  accurate  as  the 
original  operation  and  the  work  go  on  just  as  methodically. 
The  stitches  are  removed,  clots  rapidly  sponged  out  of  the 
pelvis,  and  the  cardinal  vessels  supplying  the  region  investigated 
in  turn.  When  the  one  at  fault  is  discovered  it  is  at  once 
clamped  and  quickly  tied.  If  for  any  reason  tying  would  con- 
sume too  much  time  the  clamp  may  be  left  in  place,  and  the 
abdomen  rapidly  closed  around  it  by  through-and-through 
suture.  There  is  now  no  objection  to  the  use  of  any  or  all 
avenues  for  refilling  the  vessels,  and  intravenous,  subcutaneous, 
or  rectal  saline  may  be  given  according  to  the  exigencies  of  the 
case.  In  this  connection  it  is  to  be  remembered  that  saline 
solution  does  nothing  but  restore  the  blood  pressure  and 
bring  up  the  body  temperature,  and  that  there  is  a  Kmit  to  the 


6l6  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELAE 

quantity  which  can  be  given  with  impunity.  Pulmonary 
oedema,  acute  dilatation  of  the  heart,  and  salt  retention  with 
generalized  oedema,  have  all  been  observed  in  cases  in  which 
saline  was  used  too  freely. 

Severe  post-operative  hemorrhage  following  amputation  of 
the  cervix  is  not  an  uncommon  occurrence.  This  can  usually 
be  managed  by  tight  packing,  and  always  by  the  insertion  of 
a  deep  suture  on  the  bleeding  side,  just  lateral  to  the  cervix. 
Serious  hemorrhage  following  perineorraphy  is  rare,  but  should 
it  occur  it  is  easily  met  by  suture  or  ligature.  Serious  oozing 
from  the  abdominal  incision  and  abscess  walls  sometimes  follows 
operation  upon  long-standing  pelvic  and  appendicular  abscesses. 
This  should  be  met  by  serum  injection  and  pressure  applied  by 
packing.  As  the  bleeding  area  opens  upon  the  surface  and  is 
usually  walled  off  from  the  general  abdominal  cavity  there  is 
no  objection  to  the  use  of  styptics,  such  as  adrenalin  and  anti- 
pyrin  solution,  upon  the  gauze  used  for  packing. 

POST-OPERATIVE    INFECTION 

Infection  of  Incisions. — Infection  of  the  cervix,  vaginal 
walls,  and  perineum  are  among  the  rarest  of  post-operative 
complications.  The  evidences  of  infection  are  usually  plain 
but  depend  somewhat  upon  the  infecting  organism.  Should 
this  be  the  streptococcus  there  will  be  elevation  of  temperature 
and  pulse,  local  swelling  heat  and  redness,  with  perhaps  a 
thin  sero-purulent  discharge  from  the  wound.  There  is  a 
likeHhood  also,  that  by  continuity  of  surface  or  lymphatic  and 
venous  connection,  involvement  of  structures  other  than  those 
originally  invaded  will  occur. 

Should  staphylococci  or  colon  bacilli  be  the  infecting  organ- 
isms, the  general  reaction  is  the  same  but  the  infection  is  not 
so  likely  to  spread.  Local  suppuration  and  abscess  formation, 
with  foul-smelling  pus  if  the  colon  bacillus  is  present,  will 
probably  be  the  end  of  the  matter. 


POST-OPERATIVE   INFECTION  617 

Infection  of  the  abdominal  wall  proceeds  according  to  the 
same  general  plan,  streptococcus  infection  giving  rise  to  a 
spreading  erysipelatous  inflammation,  the  other  common  pus- 
producing  organisms  to  a  local  abscess.  Simple  stitch  abscess 
is  generally  due  to  infection  by  the  staphylococcus  albus  of  the 
skin,  plus  a  tight  suture  which  has  caused  tissue  necrosis  and 
so  furnished  the  proper  culture  medium.  Hsematomata  be- 
tween the  abdominal  muscle  layers  often  become  infected  when 
the  living  tissues  would  offer  adequate  resistance  to  the  mild 
infecting  agent.  A  common  source  of  abdominal  wall  infec- 
tion is  carelessness  in  handling  the  appendicular  stump  when 
the  appendix  is  removed  through  a  median  incision.  With 
this  incision  it  is  sometimes  impossible  to  draw  the  caecum 
entirely  out  of  the  abdominal  cavity,  and  in  consequence  the 
stump  of  the  appendix  is  rubbed  against  the  sides  of  the  incision 
unless  the  latter  is  well  covered  with  pads  previous  to  severing 
the  appendix  from  the  gut. 

Treatment. — The  parts  being  at  rest,  free  drainage  is  the  first 
essential,  and  to  this  end  the  stitches  in  the  infected  area  should 
be  removed  and  the  edges  of  the  incision  separated  if  necessary. 
Fortunately,  the  inflammatory  process  is  Hkely  to  be  confined 
to  the  tissue  of  lowest  vitaHty,  which  is  the  subcutaneous  fat,  and 
when  this  is  true  the  integrity  of  the  incision  as  a  whole  is  not 
jeopardized.  Should  the  infection  result  in  a  localized  ab- 
scess, drainage  is  all  that  is  required,  although  the  discharge  will 
not  entirely  cease  until  any  suture  material  that  has  been  soiled 
is  either  removed  or  comes  away  spontaneously.  If  there  is 
considerable  inflammatory  reaction  with  a  red  brawny  swell- 
ing extending  some  distance  from  the  wound,  more  vigorous 
measures  are  demanded.  The  stitches  should  be  removed, 
or  the  incision  opened,  and  a  culture  taken,  both  for  diagnostic 
purposes  and  for  the  preparation  of  a  vaccine  should  the  latter 
prove  necessary.  The  wound  should  be  gently  sponged  dry 
and  then  swabbed  with  full  strength  tincture  of  iodine  as  the 
germicide  most  Hkely  to  destroy  superficial  micro-organisms 


6l8  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELS 

without  lowering  the  resistance  of  the  tissues.  Moist  dressings 
of  2  to  4  per  cent,  saline  solution  combined  with  3^^  or  i  per 
cent,  citrate  of  sodium  should  be  applied  constantly  according 
to  Wright's  proposal.  The  strong  saline  solution  causes  exos- 
mosis,  while  the  sodium  citrate  keeps  the  albuminoids  in  solu- 
tion, and  both  together  tend  to  promote  constant  drainage  from 
the  tissues  into  the  wound.  If  the  inflammatory  process  does 
not  subside  promptly,  an  autogenous  vaccine  should  be  made, 
and  at  the  same  time  citric  acid  may  be  given  internally  in 
accordance  with  Wright's  views  concerning  its  efhcacy  in 
lessening  the  coagulability  of  the  blood  and  so  allowing  the 
antibodies  to  penetrate  nearer  to  the  actual  focus  of  infection. 

After  a  day  or  two  of  saline  dressings  the  wound  sometimes 
becomes  quite  painful,  when  a  lo  per  cent,  alcoholic  solution 
of  boric  acid  will  be  found  useful  as  an  alternative.  It  is 
needless  to  say  that  the  dressing  of  such  cases  must  be  done  with 
great  care,  and  all  utensils  be  kept  separate  from  those  used  for 
other  patients.  The  soiled  dressings  should  be  cremated  im- 
mediately. The  ease  with  which  infection  is  carried  to  an 
entire  ward  is  shown  by  the  persistence  with  which  bacillus 
pyocyaneous  infections  cHng  to  a  hospital  division.  The 
transference  of  this  infection  is  never  in  doubt,  since  the 
blue  pus  which  appears  first  in  one  case  and  then  in  another, 
makes  its  spread  recognizable  to  the  naked  eye. 

Peritoneal  Infection. — Infection  of  the  peritoneum,  intro- 
duced from  without  at  the  time  of  operation,  is  virtually  un- 
known under  modern  aseptic  methods,  but  post-operative 
peritonitis  always  will  exist  owing  to  occasional  intestinal  injury 
during  the  performance  of  a  difhcult  operation  compHcated  by 
the  presence  of  many  adhesions,  and  to  the  possibility  of  con- 
taminating normal  peritoneum  during  operations  upon  infected 
fibroids,  gangrenous  tumors,  and  pus  tubes  not  yet  sterile. 

Elaborate  attention  to  details,  the  walling  off  of  uninvaded 
peritoneal  surfaces,  and  close  attention  to  intestinal  in- 
juries together  with  drainage  when  necessary,  prevent  all  but 


POST-OPERATIVE  PERITONEAL  INFECTION  619 

a  very  few,  but  now  and  then  a  case  will  develop  regardless  of 
all  precautions. 

Post-operative  local  peritonitis  is  manifested  by  the  same 
set  of  symptoms  that  are  present  in  local  peritonitis  when  no 
operation  has  been  performed;  pain,  tympany,  elevation  of 
temperature,  and  the  development  of  a  mass,  being  the  most 
significant.  As  a  rule  there  is  no  difficulty  in  making  a  diag- 
nosis when  the  nature  of  the  preceding  operation  is  taken  into 
consideration. 

The  more  dangerous  forms  of  diffuse  and  general  peritonitis 
which  follow  operation,  present  symptoms  similar  to  those 
following  visceral  perforation  and  other  primary  causes  of 
peritonitis.  In  the  worst  types  there  may  be  little  or  no  eleva- 
tion of  temperature  and  few  local  symptoms,  but  the  pulse  is 
progressively  worse  from  hour  to  hour,  vomiting  is  persistent, 
and  the  patient  succumbs  to  the  infection  within  two  or  three 
days  of  its  onset.  Other  cases  are  not  so  rapidly  fatal  and 
there  is  some  effort  at  reaction.  The  temperature  and  pulse 
both  rise,  vomiting  while  persistent  is  not  constant,  there  is 
abdominal  pain  and  the  distension  may  be  enormous,  while 
rigidity  is  pronounced  over  the  entire  abdomen. 

Treatment. — In  the  worst  cases  of  post-operative  general 
peritonitis  treatment  of  any  sort  is  unavailing.  The  patient 
presents  the  f acies  of  a  fatal  illness  from  the  outset  and  nothing 
stays  the  progress  of  the  disease.  In  milder  forms  of  post- 
operative diffuse  peritonitis,  the  mere  insertion  of  a  large  drain- 
age tube,  together  with  the  sitting  posture,  constant  rectal 
infusion,  and  absolute  prohibition  of  food  and  drink  by  the 
mouth,  may  assist  in  localizing  the  infection  before  it  has 
invaded  the  entire  abdomen.  Morphia  may  be  given  in 
sufficient  doses  to  control  peristalsis  and  pain  after  the  diagnosis 
is  established. 

In  purely  localized  infections  peristalsis  must  be  controlled 
and  cathartics  be  absolutely  avoided.  The  appearance  of  a 
mass  should  lead  to  a  constant  watch  for  the  formation  of 


620  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELAE 

pus,  which  should  be  evacuated  through  the  original  incision  if 
this  does  not  involve  drainage  between  free  coils  of  intestine. 
If  the  abscess  points  toward  the  vaginal  fornix  it  can  be  opened 
under  local  anaesthesia.  If  drainage  was  used  at  the  original 
operation  the  abscess  may  rupture  into  the  drain  tract,  but 
one  should  not  wait  too  long  for  this  to  occur  lest  rupture  into 
the  free  abdominal  cavity  take  place  with  a  rapidly  fatal 
outcome. 

Post-operative  Intestinal  Obstruction. — Intestinal  obstruc- 
tion following  pelvic  operations  may  be  early  or  late,  partial  or 
complete.  It  may  be  due  to  incarceration  of  a  loop  of  gut  under 
an  old  band  of  adhesions  or  through  an  opening  accidentally 
made  in  the  omentum  or  mesentery,  or  it  may  be  due  to  kink- 
ing of  a  coil  of  intestine  which  has  become  adherent  to  a  raw 
area  left  by  the  operation  itself.  Paralytic  obstruction  is  not 
true  obstruction,  and  is  due  either  to  too  much  handling  of  the 
intestine,  traction  on  its  mesentery,  or  most  frequently,  to 
peritoneal  infection. 

True  obstruction  is  manifested  by  persistent  vomiting 
without  elevation  of  temperature,  and  by  rhythmic  abdominal 
pain  associated  with  visible  or  audible  violent  peristalsis. 
Tympany  gradually  becomes  pronounced  and  coils  of  distended 
intestine  may  be  visible  if  the  abdominal  wall  is  thin.  Vomit- 
ing is  more  marked  the  higher  the  obstruction,  the  bowels  are 
obstinately  constipated,  and  flatus  is  expelled  in  small  quan- 
tities and  with  great  difficulty.  If  obstruction  is  complete,  the 
bowels  refuse  to  move  altogether  and  no  flatus  is  expelled  after 
that  portion  of  the  bowel  below  the  obstruction  is  emptied. 

The  striking  features  of  post-operative  obstruction  are: 
the  transition  of  ordinary  post-operative  pain  into  colicky 
rhythmic  attacks,  refusal  of  the  bowels  to  move  with  enemas, 
violent  peristalsis,  vomiting  which  becomes  intestinal  if  the 
obstruction  is  high,  feculent  if  it  is  in  the  large  intestine,  all  at 
first  with  a  normal  temperature  and  a  pulse  rate  in  proportion 
to  the  shock  which  the  obstruction  is  causing. 


POST-OPERATIVE   INTESTINAL   OBSTRUCTION 


621 


Treatment. — ^The  treatment  must  be  prompt  in  proportion 
to  the  severity  of  the  case.  Delay  in  a  bad  case  is  absolutely 
fatal.  If  obstruction  is  suspected  no  morphine  should  be  given 
until  the  diagnosis  is  made  and  the  treatment  decided  upon. 
Cathartics  are  positively  contra-indicated.  They  may  at  any 
time  convert  a  partial  into  a  complete  obstruction  by  caus- 
ing the  accumulation  of  gas  and  liquids  above  the  point  of 
narrowing,  with  resulting  torsion  of  the  gut  upon  its  mesentery. 


Fig.  269. — Manner  of  production  of  complete  intestinal  obstruction  by  torsion 
of  proximal  limb  due  to  use  of  cathartics. 

If  the  symptoms  are  very  mild  a  little  temporizing  with  enemas 
and  stomach  lavage  is  allowable  in  the  hope  that  the  intestine 
will  straighten  itself,  but  too  much  procrastination  may  see 
the  patient  beyond  the  possibility  of  recovery. 

There  is  nothing  in  all  surgery  which  taxes  the  courage  and 
surgical  resources  more  severely  than  an  operation  for  intestinal 
obstruction  soon  after  a  difficult  abdominal  operation,  but 
there  is  no  alternative. 


62  2  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELS 

The  abdomen  is  re-opened  through  the  original  incision  if 
that  has  been  made  above  the  pubis;  otherwise  an  incision  is 
made  which  will  most  readily  give  access  to  the  operative 
field.  As  soon  as  the  abdomen  is  opened  the  most  distended 
portion  of  the  intestine  may  appear  in  the  incision,  and  if  it 
does  not  it  should  be  sought  at  once.  In  running  over  the 
intestinal  coils  the  paler,  less  distended  loops,  invariably  are 
farthest  from  the  seat  of  constriction;  the  more  distended, 
fuller,  and  congested  the  bowel,  the  nearer  is  one  approaching 
the  site  of  obstruction.  When  the  constriction  is  reached,  one 
may  find  to  his  great  relief  that  recent  adhesions  can  be  sep- 
arated readily  with  the  finger  even  if  they  are  entirely  out  of 
sight.  Great  gentleness  is  necessary  at  this  time  or  the 
thinned  out  intestine  may  tear  or  give  way  at  the  point  of 
constriction.  Should  the  adhesions  be  dense  there  is  nothing 
to  do  but  expose  them  fully,  as  the  likelihood  of  serious  injury  to 
the  bowel  is  great,  and  separation  of  dense  adhesions  without 
the  aid  of  the  sight  may  result  in  a  laceration  of  the  intestine 
and  an  immediate  fatality.  Having  relieved  the  obstruction, 
the  damaged  intestine  is  brought  entirely  outside  the  abdomen 
for  inspection,  when  two  points  will  demand  consideration, 
viz.,  first,  the  condition  of  the  constricted  area  itself,  and 
second,  the  apparent  damage  to  the  intestine  above  the  con- 
striction. Upon  the  first  of  these  is  determined  the  next  step, 
which  may  be  to  return  the  intestine  to  the  abdomen  without 
further  interference,  to  over-sew  a  suspicious  area  before  re- 
turning it,  or  to  resect  the  entire  involved  loop.  Upon  the 
second,  one  decides  whether  to  evacuate  the  proximal  loop 
before  returning  the  intestine  to  the  abdominal  cavity. 

Rapid  return  of  the  circulation  in  the  involved  loop,  purple 
or  even  black  discoloration  at  the  site  of  the  constriction,  if  the 
peritoneum  is  still  smooth  and  the  tonicity  of  the  muscular  layer 
is  not  destroyed,  mean  that  the  damaged  intestine  will  return 
to  normal  without  perforation,  and  the  abdomen  should  be  closed 
as  speedily  as  possible. 


POST-OPERATIVE   INTESTINAL   OBSTRUCTION 


623 


A  doubtful  condition  of  the  intestine,  if  the  patient  were  in 
poor  shape  for  further  operation,  would  lead  one  to  lay  the  sus- 
pected coil  upon  the  surface  of  the  abdomen  or  just  beneath  the 
incision  and  pack  around  it,  so  that  perforation  would  not 
lead  to  general  soiling  of  the  peritoneum.  A  very  narrow  ring 
which  seems  likely  to  become  gangrenous  can  be  over-sewed  with 


Fig.  270. — Intestinal   obstruction.     Oversewing   a   narrow   ring   which   might 
become  gangrenous  and  perforate. 


Lembert  stitches  in  such  a  manner  as  to  turn  the  suspected 
portion  into  the  interior  of  the  intestine  and  so  obviate  soiHng 
should  the  damaged  area  give  way.  A  very  bad  condition  of 
the  intestine,  signalized  by  grayish  discoloration  and  loss  of 
peritoneal  luster,  demands  resection  if  the  damaged  gut  can 
be  drawn  outside  the  abdominal  cavity. 


624  POST-OPERATIVE   COMPLICATIONS   AND    SEQUEL.E 

INTESTINAL    RESECTION.       END-TO-END   ANASTOMOSIS 

The  whole  incision  and  all  exposed  intestine  should  be  covered 
with  several  layers  of  dry  pads,  and  the  intestine  be  doubly 
clamped  at  each  end  of  the  loop  to  be  removed.  The  clamps 
proximal  to  the  gangrenous  area  should  be  placed  far  enough 
away  to  take  in  any  ulcerated  mucosa  which  is  visible  from  the 
exterior  of  the  gut. 

The  clamps  which  are  placed  on  the  portion  of  the  bowel  to 
be  removed  may  have  bare  jaws,  but  those  which  will  remain 


Fig.   271, — Intestinal    obstruction.     Gangrene.     Resection.     The    intestine    is 
doubly  clamped  at  each  end  of  the  loop  to  be  removed. 

on  the  ends  which  are  to  be  joined  should  be  covered  with  rubber 
tubing. 

The  intestine,  between  the  pairs  of  clamps  at  each  end  of  the 
damaged  loop,  is  now  cut  somewhat  obUquely,  so  that  the  margin 
of  the  intestine  opposite  the  mesentery  is  not  deprived  of  its 
blood  supply.  The  cut  ends  are  sponged  clean,  the  loop  to  be 
removed  thoroughly  wrapped  in  a  towel,  its  mesentery  clamped 
and  cut  between  the  forceps  and  gut,  and  the  resected  portion 


INTESTINAL  OBSTRUCTION:  INTESTINAL  RESECTION   625 

at  once  disposed  of.  The  mesentery  is  quickly  tied  with  suture 
ligatures  and  the  ends  of  the  intestine  brought  together  and 
united  with  two  rows  of  continuous  stitches,  an  inner  haemos- 
tatic and  tension  row,  and  an  outer  for  the  approximation  of 
the  serous  surfaces  upon  which  approximation  intestinal 
anastomosis  depends  for  its  safety.  Suturing  is  sometimes 
easier  if  the  ends  of  the  cut  intestine  are  caught  with  a  temporary 
stitch  on  their  free  margin,    thus   allowing  the  sewing  to  be 


Fig.  272.— Intestinal  obstruction.  Gangrene.  Resection.  The  involved 
loop  has  been  severed  at  each  end.  The  mesentery  is  being  clamped.  Note 
gauze  protection  of  all  exposed  mucosa. 

done  in  halves,  but  this  is  not  necessary  if  the  clamps  are 
properly  placed.  Leakage  after  intestinal  resection  is  most 
likely  to  occur  at  the  mesenteric  margin  of  the  gut  in  which 
locahty  it  is  not  covered  by  peritoneum,  and  this  margin  should 
receive  special  attention. 

The  inner  stitch  of  fine  chromic  catgut  penetrates  all  the 
coats  of  the  intestine,  and  it  should  begin  at  one  side  of  this 
uncovered  area  so  that  it  may  not  be  disturbed  by  knots.     At 
40 


626 


POST-OPERATIVE    COMPLICATIONS   AND    SEQUELS 


its  beginning  this  stitch  passes  from  the  mucosa  of  one  side, 
through  all  the  intestinal  coats,  and  emerges  on  the  mucosa 
of  the  other  side.  It  is  tied  and  then  continued  around  the  cut 
edges  of  the  bowel  until  the  free  margin  opposite  the  mesentery- 
is  reached.  It  facilitates  sewing  to  tie  the  stitch  at  this  point, 
and  then  reverse  the  needle  in  such  manner  as  to  penetrate  from 


Q 

K 

/ 

— 

=== 

SSA  ^^P^!^P 

■V 

A 

ii 

P"' 

\ 

i 

irrvv,^^ 

X 

V 

1 

} 

Fig.  273. — Intestinal  obstruction.  Resection.  End-to-end  anastomosis.  The 
inner  stitch  penetrates  all  the  coats  of  the  intestine,  and  the  first  knot  is  at  one 
side  of  the  portion  of  gut  not  covered  by  peritoneum. 

the  peritoneum  of  one  side  through  all  the  coats  of  both  ends  and 
out  on  the  peritoneal  surface  of  the  opposite  side.  In  this 
fashion  the  cut  edges  of  that  half  of  the  intestine  sewn  last, 
show  the  margin  of  the  mucosa,  and,  as  Moynihan  has  pointed 
out,  bleeding  is  readily  seen  and  controlled  if  the  clamps  are 
removed  before  the  serous  stitch  is  begun.  The  serous  stitch 
should  start  on  the  mesentery  proximal  to  its  attachment  to 


INTESTINAL   OBSTRUCTION:  INTESTINAL  RESECTION       627 

the  gut,  so  that  several  stitches  are  passed  before  the  gut  itself 
is  reached.  Just  below  the  attached  margin  of  the  gut  the 
stitch  passes  through  the  mesentery  to  the  opposite  layer  of 
peritoneum.  It  then  crosses  the  cut  edges  of  the  mesentery 
and  perforates  that  in  the  reverse  direction,  so  that  a  mattress 
suture  is  formed  which  holds  the  mesenteric  layers  together  as 


Fig.  274. — Intestinal  obstruction.  Resection.  End-to-end  anastomosis. 
The  anterior  portion  of  the  through-and-through  inner  stitch  is  completed.  The 
needle  takes  a  turn  through  the  cut  edges  of  mesentery. 

well  as  approximating  their  cut  edges.  This  stitch  is  then  con- 
tinued around  the  intestine  in  the  Lembert  fashion,  picking 
up  no  mucosa  in  its  course.  The  serous  stitches  should  be 
close  together  and  turn  in  a  liberal  area  of  peritoneum.  With 
reasonable  care  there  is  no  danger  of  forming  a  diaphragm  wide 
enough  to  interfere  with  the  fecal  circulation. 

Having  completed  the  operation,  the  intestine  is  thoroughly 


628 


POST-OPERATIVE   COMPLICATIONS   AND   SEQUELS 


washed,  the  pads  removed,  all  gloves  and  instruments  changed, 
and  the  abdomen  closed.  In  intestinal  resection  for  chronic 
disease  it  is  sometimes  wiser  to  establish  an  end-to-side  or  a 


Fig.  275. — Intestinal  obstruction.  Resection.  End-to-end  anastomosis. 
The  first  or  inner  row  of  sutures  is  finished  and  the  mesenteric  gapais  closed 
by  catgut  stitches. 

side-to-side  anastomosis  rather  than  an  end-to-end  joint,  but 
this  necessitates  more  suturing  and  requires  more  time,  and 
in  post-operative  obstruction  time  is  of  the  greatest  value. 
The  Murphy  button  is  often  used  in  anastomosis  in  order  to 


INTESTINAL  OBSTRUCTION:  INTESTINAL  RESECTION   629 

save  time,  but  the  fingers  can  do  the  work  as  rapidly  as  the 
button  if  the  latter  is  carefully  apphed,  and  the  uncertainty 
of  the  button  makes  it  less  desirable  than  needle  and  thread. 

Whether  or  not  resection  is  necessary,  evacuation  of  the 
bowel  contents  above  the  constriction  is  advised,  especially  if 


Fig.  276, — Intestinal  obstruction.  Resection.  End-to-end  anastomosis. 
The  serous  stitch  should  start  on  the  mesentery.  Lembert  sutures  are  shown  on 
bowel,  but  each  stitch  should  be  tightened  before  its  successor  is  placed. 

there  is  much  distension  and  an  ulcerated  mucosa.  This 
advice  is  based  on  a  belief  that  the  healthy  gut  will  absorb  so 
much  of  the  toxic  material  poured  into  it  from  above  as  to 
cause  fatal  poisoning.  After  trying  both  evacuation  and  no 
evacuation,  the  author  is  unable  to  see  any  material  advantage 


630 


POST-OPERATIVE   COMPLICATIONS  AKD   SEQUELS 


and  has  given  it  up  as  a  routine  procedure,  although  the  weight 
of  authority  is  in  favor  of  enterostomy  with  immediate  closure 
of  the  opening  after  all  the  bowel  contents  are  expelled  that  can 
be  coaxed  into  the  opened  coil. 

Very  recently  there  has  been  experimental  work  which 
makes  it  seem  possible  that  absorption  of  toxic  duodenal 
secretions  is  responsible  for  some  of  the  disasters  which  follow 


Fig.  277. — Illustration  shows  portion  of  bowel  wall  at  mesenteric  edge  which  is 
not  covered  by  peritoneum.  Also  how  penetrating  both  leaves  of  mesentery  by 
mattress  stitch  narrows  this  gap. 


operation  for  acute  obstruction.  Should  this  prove  to  be 
true,  a  high  jejunostomy  with  temporary  drainage  of  the 
duodenum  may  avert  some  of  the  deaths  which  certainly  seem 
to  be  due  to  toxaemia. 

Two  circumstances  demand  the  formation  of  an  enterostomy 
or  fecal  fistula.  When  a  search  for  the  obstruction  would 
break  up  protective  adhesions  about  a  badly  infected  focus, 
a  fecal  fistula  is  the  lesser  of  two  evils,  and  if  the  obstruction 


INTESTINAL   OBSTRUCTION:   ENTEROSTOMY 


631 


cannot  be  overcome  when  found,   enterostomy  is  our  only 
resource. 

Only  a  temporary  drainage  opening  being  desired,  the  elabo- 
rate technique  which  is  required  when  a  permanent  fistula  is  to 
be  established  is  unnecessary. 


Fig.  278.— Enterostomy.     A  temporary  opening  only  is  required.     Close  set 
stitches  uniting  peritoneum  of  abdominal  wall  to  gut.     Suspension  stitch  placed. 

Enterostomy. — The  most  distended  loop  of  bowel  is  brought 
up  through  the  incision  and  a  sero-serous  approximation  made 
between  the  parietal  peritoneum  and  gut.  The  stitches  should 
be  so  closely  and  accurately  taken  that  no  leakage  is  possible. 


632  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELAE 

A  suspension  stitch  is  taken  at  each  end  of  the  projecting  loop, 
which  stitch  passes  through  the  skin  and  subcutaneous  tissue 
and  just  pierces  the  intestinal  peritoneum  and  muscle.  If  the 
condition  of  the  patient  is  such  that  the  gut  must  be  opened  im- 
mediately, a  purse-string  suture  is  inserted  in  the  convex  border 


Fig.  279. — Enterostomy.     Insertion  of  purse-string  suture  and  tube. 

of  the  intestine,  the  abdominal  incision  thoroughly  protected 
with  rubber  dam  and  sponges,  the  intestine  opened,  a  tube  quickly 
inserted,  and  the  purse  string  tied.  The  purse  string  prevents 
leakage  for  a  day  or  two,  after  which  time  sufficient  adhesions 
have  formed  to  protect  the  peritoneal  cavity.     If  opening  of 


INTESTINAL   OBSTRUCTION:   ENTEROSTOMY 


^2>Z 


the  intestine  can  be  deferred  for  24  hours  it  is  safer  to  do  so, 
when  a  simple  incision  with  the  cautery  is  made  through  the 
convex  surface  of  the  protruding  loop,  to  give  vent  to  the  re- 
tained gas  and  liquid  contents  of  the  intestine. 

It  is  the  habit  of  some  operators  to  establish  a  fecal  fistula 
for  practically  all  cases  of  post-operative  obstruction,  but  as 
this  necessitates  still  another  operation  of  gravity  it  should 
be  avoided  when  at  all  possible. 


Fig.  280. — Enterostomy.     Diagram  showing  tube  in  place  for  temporary- 
drainage  of  gut. 

Fecal  Fistula. — Fecal  fistulae  follow  pelvic  operations  less 
frequently  in  the  practice  of  those  who  never  use  drainage. 
This  is  not  because  drainage  causes  fistula,  but  rather  because 
intestinal  perforation  in  the  closed  abdomen  is  so  promptly 
fatal  that  fistula  does  not  result. 

It  must  be  admitted,  however,  that  the  old  glass  drains  did 
cause  an  occasional  fistula,  but  soft  rubber  tubes  and  gauze 
do  not. 


634  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELAE 

Fecal  fistulae  are  the  result  of  enterostomy  for  obstruction, 
of  operative  accident,  of  pre-operative  perforation  of  a  pus  tube 
or  other  abscess  into  the  intestine,  or  of  such  damage  to  the 
bowel  wall  that  sloughing  takes  place.  Those  fistulae  which 
make  their  appearance  soon  after  operation  are  more  likely  to 
close  spontaneously  than  those  appearing  later,  as  the  former 
are  usually  due  to  injury,  while  the  latter  are  caused  by  slough- 
ing and  actual  loss  of  tissue.  Nearly  all  fecal  fistulae  close  spon- 
taneously, after  a  greater  or  less  lapse  of  time,  unless  there  is 
some  obstruction  distal  to  the  opening  in  the  intestine.  The 
symptoms  are  perfectly  plain  and  consist  in  the  appearance 
of  intestinal  contents  on  the  dressings.  In  fistulae  that  are 
due  to  sloughs  in  the  intestinal  wall,  the  appearance  of  fecal 
matter  is  sometimes  preceded  for  a  day  or  two  by  an  un- 
accountable rise  in  temperature  and  pulse. 

Treatment. — The  treatment  at  first  consists  of  frequent  change 
of  dressings  and  efforts  to  prevent  excoriation  of  the  skin,  but 
if  the  fistula  is  high  in  the  small  intestine  some  excoriation 
will  take  place  in  spite  of  all  precautions.  Sometimes  silver 
foil  applied  to  the  skin  in  the  vicinity  alleviates  this,  and  oint- 
ments with  fatty  bases  divert  the  discharge  without  allowing 
it  to  lie  too  long  in  contact  with  the  skin.  Cleansing  of  the 
skin  should  be  done  with  boric  acid  or  saline  solution  only,  as 
alcohol  and  bichloride  solutions  give  rise  to  unnecessary  pain. 
If  the  fistula  is  in  the  large  intestine,  the  bowels  should  be  kept 
loose  and  the  drainage  tube  be  retained  until  it  is  certain  that 
the  fecal  matter  can  escape  readily.  Some  fistulae  close  very 
promptly  if  drainage  is  well  maintained;  others  close  perma- 
nently after  several  temporary  closures  which  are  followed  by 
spontaneous  re-opening.  If  the  fistula  is  permanent  it  rests 
with  the  patient  to  decide  whether  its  inconvenience  and  dis- 
comfort are  sufficient  to  justify  an  operation  for  its  cure. 
Operation  is  comparatively  simple  if  the  leaking  intestine  is 
near  the  surface  or  adherent  to  the  scar,  and  extremely  difh- 


FECAL   FISTULA 


635 


cult  if  the  damaged  bowel  is  buried  in  adhesions  deep  in  the 
pelvis. 

If  the  fistula  is  short,  the  involved  coil  may  be  cut  down  upon 
directly,  the  fistulous  tract  excised,  and  the  opening  in  the  gut 
closed  by  two  or  three  layers  of  sutures  after  the  bowel  is 
sufficiently  mobilized,  which  should  be  accomplished  without 
wide  invasion  of  the  free  peritoneal  cavity. 

The  operation  will  rarely  be  so  simple  as  this,  most  persistent 
fistulae  being  tortuous  and  complicated  by  narrowing  of  the  gut 
distal  to  the  opening. 


Fig.-  281.  Fig.  282. 

Fig.  281.^ — Fecal  fistula  in  midline  below  umbilicus.    Location  of  skin  incision. 

Fig.  282. — Fecal  j&stula.  The  abdomen  has  been  opened  where  it  is  free  from 
adhesions.  The  incision  is  prolonged  alongside  the  fistula  and  the  involved  coil 
gradually  withdrawn. 

In  these,  the  skin  should  be  carefully  steriHzed,  the  fistulous 
tract  cauterized  at  its  exit  and  tightly  packed  with  gauze. 
The  abdomen  is  then  cautiously  opened  at  a  point  from  which 
adhesions  presumably  are  absent. 

Adhesions  should  now  be  separated  and  the  incision  enlarged 
alongside  the  fistula  until  the  involved  coil  is  demonstrated, 
when  it  is  loosened  thoroughly  and  brought  outside  the  ab- 
domen. Sometimes  the  opening  in  the  bowel  is  small  and  can 
be  closed  with  two  rows  of  sutures  over  which  a  graft  of  omen- 


636 


POST-OPERATIVE    COMPLICATIONS   AND    SEQUELAE 


turn  is  tacked  with  two  or  three  stitches;  at  others  the  whole  of 
the  coil  will  need  to  be  resected  to  get  rid  of  a  narrowed  por- 
tion, or  the  opening  will  be  so  large  and  the  intestine  so  in- 
filtrated that  simple  closure  can  not  be  practised. 


Fig.  283. — Fecal  fistula.     Resection  of  involved  loop  as  in  intestinal 

obstruction. 


INTESTINAL  RESECTION — LATERAL  ANASTOMOSIS 

When  resection  must  be  done  the  portion  to  be  resected 
should  be  removed  as  indicated  under  intestinal  obstruction, 
after  careful  protection  of  the  abdominal  cavity,  but  lateral 


FECAL  fistula:   INTESTINAL   RESECTION  637 

anastomosis  will  more  likely  be  practised  than  end-to-end.  Be- 
fore this  is  done  the  open  ends  must  be  closed.  This  is  readily 
accomplished  by  a  continuous  stitch  through  all  the  coats  just 
beyond  the  rubber-covered  clamps.  This  is  a  haemostatic 
stitch,  and  the  stump  thus  formed  is  inverted  by  a  continuous 


Fig.  284. — Fecal  fistula.     Resection  for.     Side-to-side  anastomosis.     Closure 
of  blind  ends  beyond  rubber-covered  clamps. 

Lembert  stitch  which  buries  it.  Rubber-covered  clamps  are 
then  placed  longitudinally  on  the  free  margin  of  the  gut  near 
the  blind  ends,  and  a  continuous  Lembert  silk  stitch  applied 
which  approximates  the  peritoneal  coats  of  the  two  loops  of 


638 


POST-OPERATIVE   COMPLICATIONS   AND    SEQUELS 


intestine  close  to  the  edges  of  the  clamps.  This  suture  should 
be  at  least  5  cm.  in  length.  Both  loops  of  intestine  are  then 
opened  i  cm.  in  front  of  the  suture  line,  and  an  inner  layer  of 
fine  chromic  gut  applied  which  passes  through  all  the  coats 
on  both  sides.  The  method  of  application  is  precisely  the 
same  as  for  the  inner  row  in  end-to-end  anastomosis;  that  is, 
the  first  half  next  the  clamp  is  passed  from  the  mucosa  of  one 
side,  through  the  entire  thickness  of  the  bowel  wall  of  both  sides, 
and  emerges  on  the  mucosa  of  the  second  side. 


Fig. 


285. — Intestinal  resection.    Lateral  anastomosis.     Detail  of  method  of  in- 
serting Lembert  stitch  to  bury  through-and-through  stitch. 


If  this  is  begun  at  one  end  of  the  incision  in  the  intestine, 
the  stitch  is  reversed  at  the  other  end,  so  that  intestinal  mucosa 
shows  along  the  anterior  suture  line.  Having  reached  the 
first  end  of  the  incision  the  suture  is  tied,  and  then  tied  again 
to  the  end  left  when  the  stitch  was  begun.  After  loosening  the 
clamps,  the  original  silk  Lembert  stitch  is  continued  until  it 
reaches  the  starting  point,  and  having  reached  the  starting 
point  is  tied  and  then  tied  again  to  the  end  of  the  suture  left 
at  the  beginning  of  the  stitch. 


FECAL  fistula:  INTESTINAL  RESECTION 


639 


The  intestine  is  thoroughly  cleansed  and  returned  to  the 
abdomen,  and  all  gloves  and  instruments  are  changed  for  the 
closure  which  follows.  If  there  is  the  least  doubt  of  the  in- 
tegrity of  the  bowel  at  the  point  of  anastomosis,  a  cigarette 
drain  is  introduced  down  to,  but  not  against,  the  suture  line. 


Fig.  286. — Intestinal  resection.  Lateral  anastomosis.  Rubber-covered 
clamps  applied  longitudinally.  Both  coils  of  intestine  opened.  Posterior 
Lembert  stitch  in  place. 


Lateral  anastomosis  is  generally  preferred  to  end-to-end  under 
these  circumstances  because  the  proximal  intestine  is  likely  to 
be  distended  and  hypertrophied  while  the  distal  is  small  and 


640  POST-OPERATIVE    COMPLICATIONS   AND    SEQUELS 

atrophic,  and  this  disparity  in  size  renders  end-to-end  union 
difficult. 

Foreign  Bodies  in  the  Abdominal  Cavity. — It  is  difficult  to 
understand  how  and  why  an  instrument  can  be  left  in  the  ab- 


FiG.  287. — Intestinal  resection.     Lateral  anastomosis.     Detail  of  passing  pos- 
terior one-half  of   through-and-through  stitch. 

domen,  but  this  accident  or  oversight  has  occasionally  happened. 
It  is  more  difficult  to  understand  why  sponges  are  not  over- 
looked more  often  than  they  are,  and  the  comparative  rarity 
of  this  untoward  event  is  a  tribute  to  the  general  skill  and 
competence  of  those  concerned  in  the  performance  of  abdominal 
operations. 


FOREIGN  BODIES   IN  THE   ABDOMEN 


641 


Cigarette  drains  and  portions  of  packing  gauze  are  sometimes 
overlooked  when  considerable  drainage  has  been  introduced, 
and  this  is  best  prevented  by  having  the  assistant  or  nurse 
note  on  the  chart  the  number  of  drains  inserted,  before  the 


Fig.  288. — Intestinal  resection.   Lateral  anastomosis.    Detail  of  passing  anterior 
one-half  of  through-and-through  stitch.    The  mucosa  is  not  turned  in. 


patient  leaves  the  surgery.     Many  methods  of  counting  sponges 
have  been  devised  in  an  effort  to  prevent  their  loss. 

Packages  containing  a  set  number  to  facilitate  counting, 
count  of  the  number  used  by  one  nurse  detailed  for  that  purpose, 
metal  tags  attached  to  each  sponge,  etc.,  have  all  been  tried, 
41 


642  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELS 

but  each  presents  the  weakness  of  human  fallability  in  the 
counting. 

The  use  of  one  or  two  large  sheets  acts  to  prevent  the  loss  of 
the  sheets,  but  does  not  prevent  the  accidental  loss  of  small 
sponges  which  may  be  placed  upon  the  instrument  table,  or 


Fig.  289. — Intestinal  resection.     Lateral  anastomosis.     Detail  of  passing  last 
half  of  Lembert  stitch.     The  clamps  have  been   loosened. 

which  were  not  removed  after  the  abdomen  was  opened.  Very 
large  sheets  of  gauze  are  clumsy  and  sometimes  become  soiled  by 
contact  with  non-sterile  portions  of  the  gowns  and  table. 
Altogether,  it  seems  that  duphcation  of  responsibiHty  offers 


FOREIGN  BODIES  IN   THE   ABDOMEN  643 

the  best  hope  of  escape  from  the  accident,  and  to  this  end  the 
sponges  are  opened  from  packages  containing  a  given  number, 
one  nurse  counts  the  sponges  placed  within  the  abdomen,  and 
one  assistant  sees  to  it  that  each  sponge  that  enters  the  abdomen 
has  a  haemostat  attached.  When  the  assistant  recovers  all 
his  haemostats,  the  nurse  her  abdominal  sponges,  and  the 
count  of  all  the  sponges  in  use  tallies  with  the  number  given 
out,  the  element  of  error  is  reduced  to  an  irreducible  minimum. 

A  small  sterile  sponge  left  in  an  uncontaminated  peritoneal 
cavity  may  become  encysted  and  cause  but  little  disturbance. 
More  frequently  there  are  indefinite  symptoms  which  are 
thought  to  be  due  to  adhesions  and  partial  obstruction. 

The  sponge  may  in  time  ulcerate  into  the  hollow  viscera,  or 
it  may  become  infected  and  give  rise  to  a  locahzed  abscess. 

A  sponge  left  in  a  septic  abdomen  keeps  up  a  discharge  from 
the  drainage  opening  long  after  the  latter  should  have  closed. 
Sometimes  a  mass  can  be  felt,  composed  of  the  sponge,  exudate, 
and  matted  viscera,  and  at  others  the  foreign  body  is  so  far 
from  the  abdominal  wall  that  nothing  out  of  the  ordinary  can 
be  palpated. 

When  the  cause  of  the  abdominal  discomfort  or  persistent 
discharge  is  known,  the  foreign  body  must,  of  course,  be  removed. 

Much  more  frequently  a  secondary  operation  is  performed 
upon  the  diagnosis  of  partial  intestinal  obstruction,  localized 
abscess,  or  imperfect  drainage,  and  the  sponge  is  revealed  as 
an  unexpected  but  very  unwelcome  factor.  There  is  nothing 
peculiar  about  a  lesion  produced  in  this  manner,  and  its  treat- 
ment should  be  based  on  general  surgical  principles  after  the 
gauze  is  removed. 

Acute  Gastric  Dilatation. — This  pecuHar,  but  dangerous  post- 
operative compKcation  has  been  explained  in  various  ways, 
none  of  which  are  wholly  satisfactory.  The  symptoms  and 
diagnosis  are  plain.  Usually  within  one  or  two  days  after 
operation  the  patient  complains  of  epigastric  and  precordial 
distress,  and  regurgitates  considerable  quantities  of  dark  brown 


644  POST-OPERATIVE   COMPLICATIONS   AND   SEQUELS 

fluid.  Coincidently  the  pulse  becomes  quickened  and  feeble 
and  the  patient  looks  very  ill.  Inspection  of  the  abdomen  shows 
marked  distension  of  its  upper  portion,  in  which  the  outline  of 
the  stomach  may  or  may  not  be  visible.  On  passing  the 
stomach  tube  large  quantities  of  gas  and  brownish  fluid  are 
evacuated.  A  fully  developed  case  of  acute  gastric  dilatation  is 
usually  fatal,  but  patients  with  lesser  degrees  recover  under 
prompt  treatment.  The  stomach  tube  should  be  passed  as 
often  as  required  to  keep  the  symptoms  in  abeyance.  This 
may  be  as  often  as  every  two  or  three  hours,  or  in  mild  cases 
perhaps  but  once  or  twice  daily.  The  stomach  should  be  kept 
absolutely  empty  of  food  and  liquids,  all  of  the  latter  being 
supplied  per  rectum.  The  patient  should  be  turned  on  the 
abdomen  and  the  foot  of  the  bed  be  elevated.  Strychnine 
should  be  given  hypodermatically  in  large  doses,  J^^o  grain 
every  four  hours,  until  the  limit  of  tolerance  is  reached  as 
shown  by  slight  stiffness  of  the  neck  and  twitching  of  the 
muscles.  Post-operative  gastro-enterostomy  is  certain  to  be 
thought  of  but  has  been  so  uniformly  fatal  in  acute  dilatation 
that  it  is  not  advised. 

Suppression  of  Urine. — ^Less  than  250  cc.  of  urine  in  24  hours 
should  lead  to  immediate  investigation.  Complete  suppression, 
in  the  absence  of  the  possibility  of  ureteral  injury,  usually 
means  an  acute  nephritis,  which  leads  to  profound  uraemia 
and  death  unless  overcome  at  an  early  date.  Nephrotomy,  on 
patients  who  have  acute  suppression,  shows  an  intensely  con- 
gested organ  swollen  tightly  under  its  capsule.  Measures  to 
relieve  the  acute  congestion  are  moist  heat  over  the  lumbar 
region,  dry  or  wet  cupping,  purgation,  hot  packs,  and,  most 
effectual  of  all,  hot  colonic  irrigation  through  a  two-way 
catheter,  continued  as  long  as  possible  without  exhausting  the 
patient,  and  repeated  two  or  three  times  daily.  If  the  case  fails 
to  respond  to  medical  treatment,  exposure  of  both  kidneys 
with  splitting  of  their  capsules  holds  forth  some  hope  of  re- 
covery.    Unless  the  patient  is  anaemic,  bleeding  from  the  wound 


LIGATION    OF    URETERS  645 

should  be  encouraged  rather  than  otherwise,  and  under  the 
same  circumstances  venesection  followed  by  intravenous  saline 
infusion  ought  to  be  of  some  benefit,  and  perhaps  should  have  a 
trial  before  any  radical  operation  is  suggested.  If  anaesthesia  is 
necessary  for  any  procedure  in  the  presence  of  acute  suppression 
of  urine,  nitrous  oxide  should  always  be  the  anaesthetic  chosen. 

Ligation  of  Ureters. — One  of  the  dangerous  accidents  which 
sometimes  occurs  during  the  performance  of  hysterectomy  and 
ovariotomy  is  ligation  or  injury  of  the  ureter.  If  ligation  is 
bilateral  the  anuria  which  results  may  be  mistaken  for  acute 
suppression  due  to  nephritis. 

Injury  to  the  ureter  which  causes  a  leakage  of  urine  into 
the  abdominal  cavity  may  prove  rapidly  fatal  if  virulent  infec- 
tion is  present,  or  in  the  absence  of  such  infection,  local  peri- 
tonitis with  abscess  formation  may  take  place,  the  opening 
of  the  abscess  leaving  a  urinary  fistula. 

Ligation  of  both  ureters  is  followed  by  uraemia  and  death 
within  a  few  days. 

Ligation  of  one  ureter,  while  a  serious  accident,  is  rarely  im- 
mediately fatal.  Experimental  work  as  well  as  clinical  ex- 
perience demonstrates  that  the  usual  outcome  of  unilateral 
Hgation  is  acute  hydronephrosis  followed  by  atrophy  of  the 
kidney  substance,  although  infection  of  the  retained  urine  may 
occur  and  cause  a  surgical  kidney.  The  character  of  the 
operation  and  the  anaesthetic  used  will  give  some  clue  as  to  the 
probable  nature  of  the  accident. 

Diminution  in  the  quantity  of  urine  and  acute  lumbar  pain, 
associated  with  the  rapid  development  of  a  swelling  in  the 
region  of  one  kidney,  is  rather  positive  evidence  of  occlusion 
of  the  ureter  on  that  side. 

Total  anuria  must  be  due  either  to  acute  nephritis  or  occlusion 
of  both  ureters,  the  latter  causing  more  severe  pain  than  the 
former. 

Treatment. — The  recognition  of  injury  to  the  ureter  is  ren- 
dered easier  if  the  patient  has  been  given  a  full  dose  of  methylene 


646  POST-OPERATIVE  COMPLICATIONS   AND   SEQUELS 

blue  on  the  night  preceding  operation.  An  injury  recognized 
when  it  occurs  should  be  repaired  at  once.  If  the  ureter  is 
completely  severed,  a  uretero-ureteral  anastomosis  should  be 
performed  if  possible,  or  the  ureter  be  implanted  in  the  fundus 
of  the  bladder.  If  both  of  these  procedures  are  impracticable, 
and  but  one  ureter  is  involved,  it  may  be  brought  out  on  the 
loin  and  a  urinary  fistula  estabHshed,  or  the  ureter  may  be  se- 
curely ligated  and  cjropped.  The  former  is  the  better  plan  and 
can  be  followed  later  by  a  nephrectomy  if  desired. 

If  the  injury  is  not  recognized  until  peritonitis  has  supervened, 
drainage  with  gauze  protection  of  the  uninvolved  portion  of  the 
peritoneum  is  indicated. 

Ligation  of  one  ureter  does  not  demand  interference  unless 
symptoms  of  kidney  infection  make  their  appearance,  when 
nephrotomy  with  drainage,  or  nephrectomy  should  be  done 
according  to  the  necessities  of  the  individual  case.  Ligation 
of  both  ureters  might  not  necessitate  interference  providing 
the  ligature  material  used  were  fine  plain  catgut.  In  the  event 
that  any  other  material  was  tied  about  the  ureters,  or  upon  the 
sHghtest  indication  of  any  uraemic  disturbance,  both  kidneys 
should  be  cut  down  upon,  the  kidney  opened  to  its  pelvis  by  a 
longitudinal  incision  just  posterior  to  its  mid-Hne,  and  a  drain- 
age tube  inserted  and  allowed  to  remain  until  the  ligatures 
about  the  ureters  absorb.  If  the  material  used  for  ligatures 
were  non-absorbable,  these  lumbar  fistulae  will  likely  be  perma- 
nent, and  will  necessitate  the  constant  use  of  a  double  urinal 
until  such  time  as  the  patient  is  strong  enough  to  submit  to 
an  operation  for  anastomosis  of  the  ureters  into  the  bladder. 

Post-operative  Bronchitis  and  Pneumonia.^ — When  bronchitis 
and  pneumonia  follow  operative  procedure  they  are  infectious 
in  their  nature  precisely  as  they  are  at  other  times.  The  exact 
manner  in  which  a  given  operation  predisposes  the  patient  to 
bronchitis  is  often  unknown,  but  general  as  well  as  local  lower- 
ing of  resistance  is  probably  a  very  important  factor.  Ether 
undoubtedly  irritates  the  bronchial  mucosa,  and  the  inhalation 


POST-OPERATIVE  BRONCHITIS   AND   PNEUMONIA  647 

of  saliva  and  mucus  from  the  mouth,  as  well  as  aspiration  of 
stomach  contents  into  the  bronchi,  act  as  predisposing  causes 
if  the  infecting  micro-organism  is  present.  Given  a  patient 
with  virulent  pneumococci  in  the  mouth,  nose,  or  throat,  and 
it  is  not  difficult  to  understand  the  onset  of  pulmonary  infec- 
tion following  any  of  the  above-mentioned  incidents  of  anaes- 
thetization.  Even  without  these,  the  effects  of  lowered  body 
temperature,  exposure  to  cold  when  perspiring  freely,  lessened 
lung  ventilation  from  inactivity  of  the  abdominal  muscles, 
and  possible  pulmonary  infarcts,  may  precipitate  an  attack 
of  bronchitis  or  pneumonia  in  persons  harboring  the  necessary 
micro-organisms. 

Add  to  the  above  those  cases  which  are  coincidences  only,  and 
it  is  not  strange  that  most  surgeons  have  as  much  fear  of  res- 
piratory as  they  have  of  abdominal  complications. 

In  patients  who  are  septic  this  risk  is  materially  increased 
by  the  presence  of  micro-organisms  in  the  blood  stream,  as 
well  as  by  possible  lymphatic  distribution  from  the  focus  of 
infection  to  the  lung.  Pleurisy  of  the  dry  type  is  not  at  all 
uncommon  following  operations  upon  any  portion  of  the 
body. 

The  symptoms  and  diagnosis  are  too  plain  to  need  discussion, 
but  a  diagnosis  of  pneumonia  often  can  be  made  before  the 
physical  evidences  are  present  by  noting  the  sudden  marked 
increase  in  the  rate  of  respiration  and  the  high  leucocyte  count. 
The  prognosis  always  is  good  in  pleurisy  and  bronchitis;  in 
pneumonia  the  outlook  invariably  is  serious.  The  treatment  of 
post-operative  pulmonary  infection  does  not  differ  from  that 
of  the  same  condition  at  other  times.  The  oppression  under 
the  sternum  which  is  felt  in  acute  bronchitis  can  often  be  re- 
lieved by  vigorous  counterirritation,  and  the  discomfort  of 
pleurisy  can  be  palliated  by  strapping  and  the  appHcation  of 
the  ice-bag.  Small  doses  of  morphia,  codia,  or  heroin  check  the 
unnecessary  cough  of  the  dry  stage  of  bronchitis,  and  larger 
doses  hypodermatically  may  be  necessary  if  pleuritic  pain  is 


648  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELS 

severe.  Altogether  only  palliation  of  symptoms  is  needed,  as 
both  pleurisy  and  bronchitis  run  a  favorable  course  uninfluenced 
by  medication. 

The  medical  treatment  of  pneumonia  is  also  symptomatic,  and 
is  wholly  unsatisfactory  so  far  as  any  influence  upon  the  course 
of  the  disease  is  concerned.  An  abundance  of  fresh  air  provides 
suflicient  oxygenation  in  spite  of  partial  pulmonary  consolida- 
tion, and  possibly  prevents  exhaustion  of  the  respiratory  centers 
through  over-stimulation  by  retained  carbon  dioxide.  Cool 
sponge  baths  and  ice-bags  to  the  head  and  precordium  certainly 
promote  the  comfort  of  the  patient  if  they  do  nothing  else. 
Ehmination  should  be  promoted  in  order  to  assist  nature  in 
ridding  the  body  of  toxines,  and  digitaHs  should  be  begun  early 
with  a  view  to  protecting  the  heart  at  the  time  of  crisis. 

Whether  the  various  pneumococcic  vaccines  are  of  any  value 
remains  unsettled,  but  some  method  of  serum  or  vaccine 
treatment  may  at  any  time  be  developed  whose  efficacy  will 
be  undoubted. 

Pulmonary  Embolism. — This  accident  is  usually  fatal.  It 
seems  to  occur  as  readily  after  a  clean  simple  operation  as  after 
one  which  is  serious  and  complicated.  Usually  a  late  de- 
velopment, it  most  frequently  is  seen  when  the  patient  is  up 
and  about  her  room,  but  why  a  clot  is  detached  from  the 
operative  site,  to  pass  through  the  veins  and  right  heart  and 
lodge  in  the  pulmonary  orifice,  is  wholly  unknown. 

The  symptoms  are  startling  and  tragic  in  their  intensity. 
There  may  be  no  premonitory  symptoms,  the  patient  gasping, 
becoming  cyanotic,  and  dying  almost  instantly;  at  other  times 
screaming  out  with  precordial  pain,  becoming  cyanosed,  un- 
conscious, and  dead  within  a  few  moments.  Only  rarely  is 
the  blocking  so  slight  that  the  oppression  and  cyanosis  continue 
for  several  hours  before  death,  and  still  more  infrequently  does 
a  patient  improve  after  the  onset,  and  finally  recover. 

The  author  once  had  a  patient  who  lived  for  four  days  with 
precordial    distress,    cyanosis,    and    high    temperature.     The 


POST-OPERATIVE    PHLEBITIS  649 

nature  of  the  illness  was  in  doubt,  but  the  autopsy  revealed  a 
small  old  clot  in  the  pulmonary  orifice,  to  which  new  layers  had 
been  added  from  time  to  time  until  the  vessel  was  entirely 
occluded. 

No  treatment  seems  to  be  of  any  avail,  although  the  heroic 
remedy  of  opening  the  thorax  and  pulmonary  artery  and  re- 
moving the  clot,  has  been  advised  and  practised  by  Trendelen- 
burg and  others.  In  the  few  cases  in  which  death  is  not  in- 
stantaneous this  can  do  no  harm,  and  one  can  see  how  it  might 
be  worth  while  in  rare  instances. 

Phlebitis. — The  question  of  whether  post-operative  phlebitis 
is  the  result  of  stasis,  infection,  or  change  in  the  coagulability 
of  the  blood  has  been  much  discussed. 

Apparently  it  is  any  one  or  all  of  the  three  in  different 
cases  and  at  different  times.  Its  appearance  in  patients  with 
marked  varicosities  of  the  veins  in  the  lower  extremities  is  not 
difficult  of  explanation,  nor  is  it  hard  to  understand  how  it 
occurs  in  septic  patients,  but  so  far  it  has  not  been  proven  to 
be  more  frequent  in  such  patients  than  in  others. 

This,  like  pulmonary  embolism,  is  ordinarily  a  late  compli- 
cation, the  first  symptom  being  pain  in  the  calf  of  the  leg,  fol- 
lowed by  a  rise  in  the  pulse  and  temperature.  The  leg  soon 
becomes  swollen  and  oedematous  and  pits  on  pressure,  but  the 
enormous  swelling  and  shiny  white  skin  of  puerperal  and 
typhoid  phlebitis  are  not  usually  seen. 

Although  rarely  of  great  severity,  the  acute  symptoms  may 
be  protracted,  sometimes  lasting  many  weeks.  The  prognosis 
is  good  as  to  life,  but  a  permanently  painful,  swollen  leg  may 
result.  In  the  mild  cases  swelling  and  pain  after  exercise  con- 
tinue from  six  months  to  a  year. 

Treatment. — The  first  principle  of  treatment  is  absolute  rest 
in  bed  until  the  acute  symptoms  subside,  the  only  probable 
danger  being  displacement  of  a  poorly  organized  recent  clot. 

Elevation  of  the  leg  and  moderate  elastic  compression  by 
means  of  thick  cotton  padding  and  a  light  bandage  fulfill  the 


650  POST-OPERATIVE   COMPLICATIONS   AND    SEQUELAE 

next  most  important  indication,  which  is  to  assist  the  venous 
return.  Smearing  with  ichthyol  is  useless.  Counterirritation 
by  means  of  tincture  of  iodine  applied  to  the  course  of  the  tender 
veins  does  no  harm  and  may  possibly  be  of  some  benefit,  and 
it  at  least  satisfies  the  patient's  demand  that  ''something  be 
done."  In  view  of  the  apparent  efiicacy  of  magnesium  sulphate 
solutions  in  relieving  subcutaneous  inflammatory  processes  else- 
where, it  would  seem  judicious  to  apply  a  hot  saturated  solu- 
tion of  this  drug  to  the  entire  leg,  wrapping  the  extremity  in 
gauze  wrung  out  of  the  solution,  covering  this  with  oiled  silk 
or  protective,  and  applying  sheet  wadding  and  a  bandage  out- 
side the  protective.  After  all  the  acute  symptoms  have  sub- 
sided gentle  massage  should  be  instituted.  This  may  be  more 
vigorous  from  day  to  day  and  should  be  continued  so  long  as 
the  leg  swells  persistently.  The  patient  should  be  provided 
with  an  elastic  stocking  or  elastic  bandage  as  soon  as  she  begins 
to  walk,  and  be  instructed  to  wear  it  constantly  when  she  is 
on  her  feet. 

Post-operative  Adhesions. — It  is  axiomatic  that  all  union 
between  peritoneal  surfaces  takes  place  through  the  medium 
of  adhesions.  To  open  the  abdomen,  remove  or  replace  or- 
gans, and  secure  just  the  desired  amount  of  adhering  surface  is 
obviously  impossible.  Undesirable  and  unnecessary  adhesions 
are  therefore  formed  in  the  peritoneal  cavity  after  its  invasion 
and,  temporarily  at  least,  these  adhesions  form  upon  any  surface 
which  has  been  abraded  or  otherwise  denuded  of  its  endothelium. 
If  any  infection  whatever  is  introduced,  even  of  the  mildest 
type,  the  number  and  extent  of  the  adhesions  is  enormously 
increased.  As  the  infection  subsides  many  adhesions  are  ab- 
sorbed, but  bands  of  some  character  are  likely  to  be  left  after 
the  process  of  absorption  is  entirely  completed. 

P'ortunately  most  adhesions  give  rise  to  no  trouble,  but  those 
which  render  immobile  a  normally  movable  organ  are  bound  to 
cause  discomfort.  If  adhesions  bind  the  intestine  to  the  ab- 
dominal wall,  discomfort  is  caused  by  peristalsis  dragging  upon 


POST-OPERATIVE   ADHESIONS  65 1 

the  sensitive  sub-peritoneal  tissues.  It  is  to  be  noted  that  a 
great  mass  of  adhesions  which  immobihzes  all  the  organs  gives 
rise  to  less  pain  than  a  few  adherent  surfaces,  and  that  adhesions 
which  drag  upon  areas  containing  few  sensory  nerves  may  be 
entirely  painless. 

The  diagnosis  of  adhesions  is  difficult  to  estabHsh  unless  their 
location  is  such  that  they  interfere  with  intestinal  peristalsis 
and  permanently  bind  the  gut  in  an  abnormal  position.  Under 
these  circumstances  a  Roentgenogram  by  a  skilful  speciahst 
will  confirm  the  suspicion  that  persistent  post-operative  pain  is 
due  to  adhesions. 

When  post-operative  adhesions  immobifize  the  uterus  or 
ovaries,  this  can  be  made  out  by  bi-manual  examination,  but 
an  exploratory  incision  is  many  times  the  only  means  of  de- 
termining whether  or  not  adhesions  to  other  viscera  are  the 
source  of  the  patient's  discomfort. 

Treatment. — Unless  the  intestinal  functions  are  interfered 
with,  one  should  not  be  in  too  great  haste  to  operate  upon 
post-operative  adhesions,  as  there  is  no  definite  assurance  that 
they  will  not  reform.  An  adherent  uterus,  fixed  in  an  abnormal 
location  or  position,  may  have  its  displacement  definitely  rem- 
edied by  a  suspension  or  fixation  operation  which  produces 
adhesions  in  another  locaHty,  and  the  hope  entertained  when 
operation  is  performed  for  adhesions  fixing  other  organs  is  that, 
although  new  adhesions  are  certain  to  form,  they  may  be  more 
favorably  situated  and  thus  be  painless.  Various  methods  have 
been  adopted  to  prevent  the  re-formation  of  adhesions  when  the 
abdomen  is  opened,  but  none  of  them  are  on  a  basis  of  scientific 
accuracy.  There  is  no  objection,  however,  to  coating  the 
denuded  area  thoroughly  with  sterile  vaseHne,  and  patients 
so  treated  seem  to  have  less  trouble  than  those  who  are  not. 

Post-operative  Psychoses. — The  various  types  of  mental 
ahenation  which  are  observed  after  operation  are  of  two  classes. 
In  one  the  patient  was  the  victini  of  a  latent  or  concealed 


652  POST-OPERATIVE    COMPLICATIONS   AND    SEQUELS 

psychosis  before  operation,  and  the  operative  procedure  served 
merely  to  uncover  the  mental  condition. 

In  the  other  the  operation  itself  was  in  some  way  more  di- 
rectly responsible  for  the  mental  condition,  although  it  is 
difficult  to  assume  that  any  operative  procedure  could  be  more 
than  an  exciting  cause,  the  predisposing  factor  in  the  form  of 
unstable  nervous  equilibrium  being  a  necessary  assumption. 

Gynaecologic  operations  are  more  likely  to  be  followed  by 
psychoses  than  operations  upon  other  portions  of  the  body 
because  the  patient's  sexual  apparatus  is  the  object  of  more 
anxiety  than  any  other,  and  the  fear  of  the  effect  of  operation 
upon  sexuality,  fecundity,  etc.,  is  more  marked  than  the  fear 
of  deformity  or  disability. 

In  addition  to  this,  the  premature  menopause  may  be  in- 
duced by  either  necessary  or  unnecessary  removal  of  the 
ovaries,  and  so  add  its  own  peculiar  disturbance  to  the  other 
etiologic  factors  mentioned. 

The  role  of  anaesthesia  in  the  production  of  post-operative 
insanity  is  questionable,  but  that  of  infection  is  undoubted. 

Apparently  post-operative  psychoses  belong  more  often  to 
the  class  first  mentioned;  that  is,  the  individual  was  really  a 
psychopath  before  operation,  and  the  stress  of  preparation  and 
operation  precipitated  a  crisis  which  would  have  occurred  sooner 
or  later  in  any  event.  It  therefore  follows  that  the  patient's 
mental  status  should  be  ascertained  before  any  operation  is 
performed,  and  operations  of  election,  such  as  perineal  repair 
for  example,  had  best  be  avoided  if  there  is  any  doubt  about  the 
mental  stability.  The  great  variety  of  operations,  which  in 
the  past  have  been  performed  upon  neurotic  or  psychopathic 
women  in  the  hope  that  cure  of  the  nervous  condition  would  be 
brought  about,  have  almost  uniformly  resulted  in  failure 
although  an  occasional  brilUant  cure  has  been  recorded.  On 
the  other  hand,  operations  of  necessity  should  be  performed  on 
their  own  account,  but  never  without  the  fullest  discussion  of 


POST-OPERATIVE   PSYCHOSES  653 

the  possible  result,  and  preferably  only  after  consultation  with 
a  competent  neurologist. 

Post-operative  mental  alienation  sometimes  can  be  prevented 
by  a  thorough  frank  explanation  which  is  designed  to  relieve 
the  patient  of  uncalled  for  anxiety  as  to  the  effect  of  the  opera- 
tion upon  her  future,  and  those  crises  which  are  sometimes 
provoked  by  the  artificially  induced  menopause,  can  be  obviated 
by  the  avoidance  of  double  castration  unless  the  latter  is  posi- 
tively demanded,  and  possibly  by  ovarian  transplantation 
into  the  abdominal  wall  when  both  ovaries  must  be  removed 
from  their  normal  location.  The  unfortunate  operative  furor, 
which  at  one  time  attacked  ovaries  the  subjects  of  microscopic 
disease  only,  caused  infinitely  more  misery  than  it  ever 
alleviated. 

Post-operative  mania  or  melancholia  should  be  referred  to  an 
alienist  at  the  earliest  possible  moment,  the  only  exception  being 
found  in  those  instances  of  mania  which  are  directly  traceable 
to  the  toxaemia  of  an  infection,  and  which  generally  recover 
when  the  latter  is  overcome. 

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Similar  Blood.     Southern  Surg,  b"  Gyn.  Trans.,  1906,  xix,  179. 
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FURNISS,  H.  D.— A  Simple  Method  of  Detecting  Injuries  of  the  Ureter  during 

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Am.  Gyn.  Soc,  1910,  xxxv,  121. 
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Surg.,  1912,  Ivi,  411. 
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107.     Abst.  Internal.  Obst.  Surg.,  Dec,  1913,  669. 
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of  One  Ureter.     /.  Exp.  Med.,  1914,  xx,  191. 
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Clinical  Gynaecology.     Am.  J.  Obst.,  1914,  Ixx,  329. 
RISLEY,  E.  H. — Post-operative  Pneumonia.     Bost.  M.  b"  S.  J.,  19 10,  clxii,  75. 
GRAVES,  W.  P. — Post-operative    Pneumonia   without  Mortality,  etc.     Bost. 

M.  b°  S.  J .,  1910,  clxiii,  497. 
BECKMAN,    E.    H. — Pulmonary    and    Circulatory    Complications    Following 

Surgical  Operations.     /.  Minn.  State  Med.  Soc,  191 1,  xxxi,  225. 
KUSTER. — Es  gibt  kein  Pramonitorisches  Puis  oder  Temperatur  symptom  der 

Thrombose  und  Embolie.     Zeitsch.  f.  Geb.  und  Gyn.,  1911,  Ixix,  1-65. 
TRENDELENBURG.— Zur  Operation  der  Embolie  der  Lungenarterien.     Zcnt. 

f.  Chirur.,  1908,  xxxv,  92. 
KLEIN. — Die  Puerperal  and  Post-operative  Thrombose  und  Embolie.     Arch. 

f.  Gyn.,  191 1,  xciv,  117. 
BULL. — Thrombosen  und  Embolien  nach  Appendicitis  Operationen.     Beitrage 

zur  klin.  Chir.,  1913,  Ixxxii,  345. 
SCHUMACHER. — Beitrage  zur  operativen  Behandlung  der  Lungenembolien. 

Arch.  f.  klin.  Chirur.,  1913,  cl,  818. 
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151- 
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191 1,  liv,  758. 
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SWEET,  CHANEY  AND  WILSON.— The  Prevention  of  Post-operative  Adhe- 
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LYMAN  AND  BERGTOLD. — Amniotic  Membrane  for  the  Prevention  of  Post- 
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BURROWS,  W.  F. — Post-operative  Intestinal  Stasis  and  the  Intra-abdominal 
Use  of  Oil.     Med.  Record,  1913,  Ixxxiv,  795. 

POPE,  S. — The  Use  of  Citrate  Solutions  in  the  Prevention  of  Peritoneal  Ad- 
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BLAKE. — What  are  the  End  Results  of  Surgery  or  Surgical  Operations  for  the 
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GORDON. — Nervous  and  Mental  Disturbances  Following  Castration  in  Women. 
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KELLY,  H.  A. — Post-operative  Psychoses.  Trans.  Am.  Gyn.  Soc,  1909,  xxxiv, 
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MITCHELL,  S.  WEIR. — Concerning  Nervous  Disturbances  Following  Surgical 
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REYNOLDS. — ^The  End  Results  of  Surgery  in  Neurasthenics  and  on  Neuras- 
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42 


INDEX 


Abdominal  auscultation,  77 
palpation,  78 
percussion,  75 
Abdominal  cavity,  foreign  body  in, 
640 
hysterectomy,  314 

pan -hysterectomy,  331 

for  carcinoma,  336 
supravaginal,  314 
incision  in  pelvic  cellulitis,  45 1 
myomectomy,  312 
hsemostasis  in,  314 
indications  for,  312 
mortality  from,  313 
uterine  incision  for,  314 
Abscess,  appendicular,  528,  547 
drainage  of,  553 
from  pelvic  peritonitis,  445 
pelvic,  445 
pelvic  cellular,  449 
pelvic  in  appendicitis,  554 

drainage  of,  554 
stitch,  617 
Acute  gastric  dilatation,  643 
symptoms  of,  643 
treatment  of,  644 
by  lavage,  644 
postural,  644 
Adhesions,  post-operative,  650 
diagnosis  of,  651 
etiology  of,  650 
infection  in,  650 
traumatism  in,  650 
treatment  of,  651 
After-care,  surgical,  600 
cathartics  in,  605 
diet  in,  605 


After-care,  heat  in,  600 

narcotics  in,  603 

of  bladder,  603 

of  bowels,  604 

position  in,  601 

rest  in,  606 

ventilation  in,  601 
"Alexander"  operation,  297 

after-treatment,  299 

for  retrodisplacements,  272 

Gersuny's  method,  298 

hsemostasis  in,  299 

hernia  after,  298 

incisions  for,  297 

indications  for,  297 
Alcohol  in  dysmenorrhea,  482 
Amenorrhea,  480 

and  tuberculosis,  64 

as  a  symptom,  62 

associated  with  obesity,  481 

from  atresia,  480 

from  chlorosis,  480 

from  infantile  uterus,  48 1 

in  anaemia,  63 

physiological,  62 

primary,  62 
etiology  of,  63 

secondary,  63 
etiology  of,  63 

significance  of,  62 

the  treatment  of,  480 
Amputation  of  the  cervix,  198 

cautery  method,  208 

circular,  202 

incisions  for,  203 
indications  for,  202 
sutures  in,  206 

for  chronic  pelvic  cellulitis,  452 

for  laceration,  201 


659 


66o 


INDEX 


Amputation,  modified  Schroeder,  201 
Schroeder  method,  198 
incisions  for,  199 
indications  for,  198 
sutures  in,  200 
Anaemia  and  amenorrhea,  63 
Anaesthesia,  572 

anoci-association,  580 

post-operative      fever      and 

shock,  580 
post-operative  pain  and,  580 
chloroform,  579, 
ether,  574 

in  asthma,  575 
in  heart  lesions,  576 
in  nephritis,  575 
in  repiratory  infections,  575 
for  examination,  69 
general  and  local,  580 
•     inhalation  anaesthesia,  574 
local,  572 

cocain  in,  572 

for  exploratory  incision,  573 
novocain  in,  573 
quinin    and  urea   hydrochlo- 
ride in,  573 
quinin  and   urea   hydrochlo- 
ride and  wound  healing,  58 1 
nitrous  oxide,  576 
disadvantages,  576 
in  abdominal  operations,  577 
nitrous  oxide  and  ether,  579 
spinal,  574 
Anaphylaxis,  484 

Anastomosis,  intestinal  end  to  end, 
624 
lateral,  636 
Angiotribe,  587 
Anomalies,  congenital,  459 
Anteflexion  of  the  uterus,  262 

dilatation  of  the  cervix  for,  263 
Dudley's  operation  for,  263 
dysmenorrhea  in,  262 
puerperal,  262 
sterility  in,  262 
Anterior  colporrhaphy,  132 


Anteversion  of  the  uterus,  260 
bladder  irritability  in,  261 
in  pregnancy,  260 
treatment  of,  261 
Antitoxins,  in  gynaecology,  493 
Anuria  from  acute  nephritis,  644 

from  ureteral  ligation,  645 
Appendectomy,  543 
drainage  after,  553 
cofferdam,  554 
vaginal,  554 
in  abscess  formation,  547 
incisions  for,  544 
ligation  of  mesentery  in,  550 
locating  appendix  in,  545 
management  of  stump  in  551 
sub-peritoneal  excision  in,  546 
Appendicitis,  acute,  526 

abscess  formation  in,  528 
clinical  course  of,  533 
diagnosis  of,  534 

from   gall-bladder   disease, 

536 
from  ileo-colitis,  534 
from  intestinal  obstruction, 

535 
from  kidney  lesions,  535 
from  thoracic  disease,  534 
from  ureteral  lesions,  535 
X-ray  in,  536 

etiology  of,  526 
mechanical,  526 
micro-organisms  in,  526 

gangrene  in,  527 

gross  pathology  of,  526 

mortality  of,  534 

peritonitis  in,  527 

symptoms  of,  529 

bladder  irritation  in,  531 
chills  in,  530 
hyperaesthesia  in,  531 
leucocyte  count  in,  531 
nausea  and  vomiting  in, 

530 
pain  in,  529 
pelvic  findings  in,  533 


INDEX 


66i 


Appendicitis,    diagnosis    of,    symp- 
toms of  rigidity  in,  531 
swelling  in,  532 
temperature  and  pulse  in, 

530 

tympany  in,  531 
over  abscess,  532 
treatment  of,  536 

early  operation  in,  536 
medical  treatment,  537 
enemas  in,  538 
heat  and  cold  in,  538 
narcotics  in,  537 
piirgatives  in,  538 
rest  in,  537 
starvation  in,  538 
with  abscess,  536 
with  peritonitis,  536 
Appendicitis  and  pelvic  lesions,  526 
and  peritonitis,  447 
chronic,  539 

definition  of,  539 
diagnosis  of,  542 

from  floating  kidney,  542 
from  mucous  colitis,  543 
from  retroversion,  542 
etiology  of,  539 
symptoms  of,  541 
dyspepsia  in,  541 
hyperaesthesia  in,  542 
leucocyte  count  in,  542 
malaise  in,  541 
pain  in,  541 
rigidity  in,  542 
temperature  in,  542 
treatment  of,  543 
tuberculous,  540 
Ascent  of  the  uterus,  251 
Asepsis  and  antisepsis,  563 

bacteria  concerned  with,  564 
hand  disinfection  in,  566 
chemical  sterilization  in,  568 
mechanical  cleansing  in,  567 
of  the  operative  field,  564 
chemical  sterilization  in,  565 
mechanical  cleansing  in,  564 


Asepsis  and  antisepsis,  preservation 
of  sterility  in,  571 
sterilization  of  surgical  material, 

568 
tissue  resistance  in,  564 
Auscultation  in  diagnosis,  77 

B 

"Baldy-Webster"  operation  for 
shortening  the  round  liga- 
ments, 302 

disadvantages  of,  305 

modification  of,  304 

sutures  in,  304 
Bartholinitis,  108 

and  gonorrhea,  108 
Baths  in  insomnia,  490 
Bier's  hyperaemia,  503 
Bimanual  examination,  rectal,  83 

vaginal,  82 
Bladder,  urinary,  35 

anatomy  of,  35 

blood  supply  of,  37 

examination  in  diagnosis,  87 

form  of,  35 

ligaments  of,  36 

lymphatics  of,  37 

mucosa  of,  36 

muscles  of,  37 

nerves  of,  37 

surfaces  of,  35 
Blood    examination    in     diagnosis, 

85 
Broad  ligaments,  39 

anatomy  of,  39 

contents  of,  39 
Bronchitis,  post-operative,  646 
Bruit,  uterine,  77 
Bubo,  chancroidal,  105 


Cancer  of  rectum,  518 
Capillary  hemorrhoid,  525 
Carcinoma  of  the  cervix,  185 

and  chronic  irritation,  185 

and  gumma,  189 


662 


INDEX 


Carcinoma  of  the  cervix,  and   sub- 
mucous fibroma,  189 
cachexia  in,   188 
death  from,  188 
discharge  in,  188 
extension  of,  187 
frequency  of,  185 
hemorrhage  in,  188 
pain  in,  188 
pathology  of,  185 
physical  signs  of,  188 
friability,  189 
induration,  188 
ulceration,  189 
treatment  of,  190 
morphine  in,  192 
operability  in,  190 
palliative  operation  in,  191 
palliative  treatment  in,  192 
Percy's     cauterization     in, 

191 
radium  in,  191 
vaginal    hysterectomy    in, 

190 
X-ray  in,  191 
of  ovary,  pathology  of,  415 
of  uterine  body,  241 
bleeding  in,  242 
curettage,  exploratory  in,  242 
discharge  in,  242 
microscope  in  diagnosis  of,  242 
pan-hysterectomy  for,  243 
radiotherapy  for,  243 
of  vagina,  166 
operation  in,  166 
radium  in,  166 
X-ray  in,  166 
Caruncle,  urethral,  iii 
Catharsis,  post-operative,  605 

pre-operative,  562 
Catheterization  and  cystitis,  510 
of  ureter,  92 
post-operative,  604 
Cautery  in  carcinoma  of  cervix,  191 
in  endocervicitis,  497 
in  recto-vaginal  fistula,  172 


Cautery  in  vesico-vaginal  fistula,  169 
Cellulitis,  pelvic  acute,  449 

after  labor,  449 

cystitis  in,  450 

from  dilatation  of  cervix,  449 

from  infection  of  uterus,  449 

incision  and  drainage  in,  450 
abdominal,  451 
vaginal,  450 

pain  in,  449 

palliative  treatment  of,  45 1 

pelvic  mass  in,  449 
characteristics  of,  450 

pulse  and  temperature  in,  449 

suppuration  in,  449 

vesical  and  rectal  tenesmus  in, 

449 

chronic,  451 

cervical  amputation  in,  452 
in  cancer  of  the  cervix,  451 
in  laceration  of  cervix,  452 
Central  point  of  perineum,  6 
Cervix,   amputation  for  atresia  of, 
469 
for  erosion,  177 

carcinoma  of,  185 

congenital  atresia  of,  469 

erosion  of,  175 

hypersecretion  from,  178 

hypertrophy  of,  183 

inflammation  of,  178 

laceration  of,  181 

normal  epithelium  of,  175 

polypi  of,  178 

stenosis  of,  184 

tumors  of,  184 
Chancre  of  vulva,  103 

calomel  locally  in,  104 

caustics  in,  104 

excision  of,  104 

features  of,  103 

lymphadenitis  in,  104 

mercury  in,  105 

Salvarsan  in,  104 

the  spirochete  in,  104 
Chancroidal  bubo,  105 


INDEX 


663 


Chancroid  of  vulva,  105 

and  phagadenic  ulcer,  106 
bacillus  of  Ducrey  in,  105 
calomel  and  bismuth  in,  105 
carbolic  acid  in,  106 
cautery  in,  106 
characteristics  of,  105 
lymphadenitis  in,  105 
mercury  locally  in,  105 

Chemical    therapy  in    gynaecology, 

^  495 

Chlorosis  and  amenorrhea,  63 
Chorio-epithelioma,  244 

after  pregnancy,  244 

extirpation  of  uterus  for,  244 

hemorrhage  in,  244 

malignancy  of,  244 

metastases  from,  244 
Chronic  endometritis,  220 

metritis,  226 . 
Clamp   and   cautery   operation   for 

hemorrhoids,  520 
Cloaca,    embryonic,   persistence   of, 

462 
Colloid  silver  in  bacteremia,  495 
Colon  bacillus  and  cystitis,  508 
Colporrhaphy,  anterior,  132 

denudation  in,  132 

Emmett's  addition  to,  136 

Hirst's  addition  to,  137 

purse-string  suture  in,  138 
Condylomata  of  vulva,  106 

acuminate,  106 

and  venereal  disease,  106 

chemical  caustics  in,  108 

fiat,  106 

radical  treatment  of,  108 

silver  nitrate  in,  106 

syphilitic,  106 

the  cautery  in,  108 
Congenital  anomalies,  459 
of  hymen,  462 
of  ovaries,  466 
of  uterine  tubes,  466 
of  uterus,  464 
of  vagina,  463 


Congenital  anomalies  of  vulva,  459 

prolapse  of  the  uterus,  254 
Corpus  luteum  cysts  of  ovary,  416 
Corpus  luteum,  50 
evolution  of,  50 
origin  of,  50 
Counter-irritation,  500 
"Crab  louse,"  116 
Crile's  anoci-association,  580 
Curettage,  283 

after-care,  285 
contra-indications  to,  283 
dangers  of,  283 
dilatation  for,  284 
in  chronic  endometritis,  221 
indications  for,  283 
in  functional  neuroses,  489 
in  sterility,  475 
instruments  for,  285 
irrigation  after,  285 
pre-operative  preparation,  283 
Cyst-adenoma  of  ovary,  pathology 

of,  418 
Cystectomy,  parovarian,  437 
Cystitis,  acute,  508 

after  hysterectomy,  508 
and  pyelitis,  510 
course  of,  510 
di£Eerential  diagnosis,  510 
etiology  of,  508 
organisms  in,  509 
symptoms  of,  509 
treatment  of,  510 

cystoscopy  in,  509,  511 
diet  in,  511 

local  treatment  of,  511 
medication  in,  511 
rest  in,  510 
urine  in,  508 
chronic,  512 
calculus  in,  512 
cystocele  in,  512 
etiology  of,  512 
infection  in,  512 
vesico-vaginal  fistula  in,  512 
chronic,  true,  512 


664 


INDEX 


Cystitis,    chronic,   differential   diag- 
nosis of,  513 
from  "irritable"  bladder, 

513 
from  renal  tuberculosis, 

513 
symptoms  of,  513 
treatment  of,  514 

drainage  in,  515 

general,  514 

hexamethylenamine     in, 

514 
local,  515 
sedatives  in,  514 
vaccines  in,  514 
in  acute  cellulitis,  450 
Cyst  of  vagina,  166 

operation  for,  166 
Cystocele,  123 

and  cystitis,  512 
anterior  colporrhaphy  for,  124 
etiology  of,  123 
perineorrhaphy  for,  124 
symptoms  of,  124 
Cystoscope,  Kelley,  89 

electric  lighted  instruments,  90 
Cystoscopy,  87 

D 

Decidual  reaction,  382 
Deciduoma  malignum,  244 
Dermoid  of  ovary,  pathology  of,  416 
Descent  of  the  uterus  (see   Prolap- 
sus uteri),  252 
Diabetes  and  pruritis  vulvas,  102 
Diet,  post-operative,  606 

pre-operative,  562 
Dilatation  and  curettage  in  dysmen- 
orrhea, 482 
of  the  cervix,  192 
asepsis  in,  193 
bougies  in,  192 
contra-indications  to,  192 
dangers  of,  193 
for  anteflexion,  263 
indications  for,  192 


Dilatation    and    curettage,    instru- 
mental, 193 
in  vaginal  myomectomy,  311 
Disinfection  of  hands,  566 
Displacement  of  uterus,  248 
Douches,  vaginal,  501 
Drainage,  593 

by  gauze,  596 
by  tube,  596 
curative,  594 
in  pelvic  cellulitis,  450 
in  pelvic  peritonitis,  447,  448 
of  abdominal  cavity,  595 
pelvic,  595 
prophylactic,  593 
vaginal,  595 
Drains,  removal  of,  597 
Dressings,  597 

abdominal,  598 
changing,  599 
vulvar,  597 
Dudley's  operation  for  anteflexion, 

263 
Dysmenorrhea  as  a  symptom,  64 
etiology  of,  64 
pain  in,  65 
treatment  of,  481 
alcohol  in,  482 
bromides  in,  481 
coal-tar  products  in,  481 
dilatation  and  curettage  in, 

482 
galvanism  in,  482 
general  measures  in,  483 
hot  applications  in,  481 
hysterectomy  in,  483 
in  obstruction,  482 
narcotics  in,  481 
oophorectomy  in,  483 
sitz  baths  in,  481 
types  of,  64 

E 

Ectopic  pregnancy   (see  Extra-uter- 
ine pregnancy),  381 
Embolism,  pulmonary,  648 


INDEX 


66s 


Endocervicitis,  178 
and  sterility,  472 
discharge  in,  179 
gonorrhea  in,  178 
infection  in,  178 
polypi  in,  178 
purulent,  179 
treatment  of,  179 

amputation  of  cervix  in,  180 
antiseptics  in,  180 
blood  letting  in,  180 
cathartics  in,  180 
cautery  in,  181 
dilatation  in,  180 
douches  in,  180 
Endometritis,  218 
acute,  218 

and  ovarian  infection,  219 
and  tubal  disease,  219 
exanthemata  in,  218 
exposure  in,  218 
gonococcus  in,  218 
leucorrhea  in,  219 
menorrhagia  in,  219 
physical  findings  in,  219 
puerperal,  218 
pyogenic  organisms  in,  218 
suppression  of  menses  in,  219 
temperature  in,  219 
treatment  of,  220 
and  sterility,  473 
and  uterine  polypi,  225 
chronic,  220 

clinical  forms,  220 

hemorrhagic    endometritis, 
221 
and   chronic   salpingitis, 

222 
and  myomata  of  uterus, 

222 
and     uterine     displace- 
ment, 222 
curettage  for,  225 
differential    diagnosis, 

224 
glandular,  223 


Endometritis,  hemorrhagic,  hemor- 
rhage in,  224 
interstitial,  223 
local  treatment  of,  225 
micro-organisms  in,  222 
pain  in,  224 
purulent  endometritis,  220 
curettage  in,  221 
discharge  in,  221 
gonococcus  in,  .220 
Schulze'  tampon  in,  221 
treatment  of,  221 
uterine    applications    in, 
221 
gonorrheal,  478 
Endometrium,  31 
Endo-pelvic  fascia,  42 
Enterostomy,  temporary,  631 

technique  of,  631 
Epithelioma  of  viilva,  no 
Erosion  of  cervix,  175 
amputation  in,  177 
bleeding  in,  176 
cancer  and,  177 
cervical  laceration  as  a  cause  of, 

176 
epithelium  in,  176 
infection  as  a  cause  of,  176 
•    leucorrhea  in,  176 

Nabothian  follicles  in,  177 
nitrate  of  silver  in,  177 
tannic  acid  in,  177 
Examination,  67 

anaesthesia  for,  69 
bimanual  rectal,  83 

vaginal,  82 
inspection  in,  71 
instruments  for,  71 
methods  of,  67 
microscopic,  84 
of  bladder,  87 
of  blood,  85 
of  urine,  86 
percussion  in,  75 
positions  for,  69 
preparation  for,  69 


666 


INDEX 


Examination,  scope  of,  68 

specular,  73 
Exercise  in  gynaecology,  491 
Excavation,  recto-uterine,  23 

vesico-uterine,  22 
External  hemorrhoids,  516 
Extra-uterine  pregnancy,  congenital 
anomalies  in,  382 
decidual  reaction  sites  in,  382 
diagnosis    after    rupture     (the 
ovum  dead),  394 
haematoma,  394 
haematocele,  394 
history  in,  394 
pain,  394 
diagnosis    after    rupture     (the 
ovum  living),  395 
false  labor  in,  396 
foetus  in,  395 
physical  findings  in,  396 
rupture  of  sac  in,  395 
symptoms  of  pregnancy  in, 
396 
diagnosis  at  time  of  rupture,  393 
abdominal  tympany   in, 

394 
from   intestinal   perfora- 
tion and  strangulation, 

393 
latent  period,  393 
recurrent  hemorrhage, 

394 

temperature  in,  394 
diagnosis     preceding     rupture, 

389 

abdominal  hyperaesthesia 

in,  391 

irregular  flow  in,  390 

menstruation  in,  389 

pain  in,  390 

physical  signs  in,  391 

sterility  in,  389 

tubal  enlargement  in,  391 

vaginal  section  in,  391 
etiology  of,  381 
salpingitis  in,  382 


Extra-uterine  pregnancy,  life  history 
of  ovum  in,  382 
prognosis  of,  397 
symptomatology  of,  388 
symptoms  at  time  of  rupture, 
392 
abdominal  tympany,  393 
collapse,  392 
pain,  392 
pelvic  mass,  393 
physical  signs,  392 
pulse,  392 
reaction,  392 
shock,  392 
temperature,  392 
tenderness,  393- 
symptoms  of  "typical  case, "  388 
menstrual    spotting     in, 

388 
missed   menstruation  in, 

388 
pelvic  pain  in,  388 
pulse  in,  388 
shock  in,  388 
temperature  in,  388 
treatment,  after  rupture,  401 
after  false  labor,  403 
the  foetus  living,  402 
vaginal  section  in,  403 
for  haematocele,  403 
treatment,  at  time  of  rupture, 
398 
palliative,  400 
surgical,  399 

anaesthesia  in,  400 
haemostasis  in,  401 
Trendelenburg       posi- 
tion, 400 
treatment    preceding    rupture, 
398 


False   labor   in    extra-uterine   preg- 
nancy, 396 
Fascia,  cndo-pelvic,  42 


INDEX 


667 


Fascia,  pelvic,  41 
Fecal  fistula,  633 
drainage  in,  633 
etiology  of,  633 
formation  of,  631 
treatment  of,  634 
operative,  635 
incision  for,  635 
intestinal  resection  for,  636 
Fibroids  and  sterility,  473 
Fibromata  of  ovary,  415 
of  the  uterus,  227 
and  pregnancy,  235 
carcinomata  and,  234 
cervix  in,  235 
classification  of,  231 
degeneration  of,  233 
differential  diagnosis  of,  235 
from  ascites,  237 
from  carcinoma,  236 
from  obesity,  236 
from  ovarian  tumors,  237 
from  phantom  tumors,  236 
from  pregnancy,  236 
endometritis  in,  234 
hemorrhage  in,  234 
histology  of,  232 
in  colored  race,  227 
in  sterile  women,  227 
medical  treatment  of,  238 
pressure  symptoms  in,  234 
sarcomata  and,  234 

sterility  in,  235 
surgical  treatment  of,  239 
choice    of    operations   for, 

240 
indications  for,  239 
X-ray  and  radium  in,  239 
of  the  vulva,  no 
Fibrous  polypi,  225 

G 

Gangrene  of  appendix,  527 
Gastroptosis,  556 


"Gilliam"    operation    for    retrodis- 
placements,  273 
for     shortening     round     liga- 
ments, 301 
advantages  of,  302 
disadvantages  of,  302 
incision  for,  300,  301 
Glands,  cervical,  31 

uterine,  31 
Glandular  endometritis,  223 
Gonococcus  of  Neisser,  476 
Gonorrhea,  acute,  475 

and  Bartholinitis,  476 
discharge  in,  477 
gonococcus  in,  477 
of  external  genitalia,  476 
of  internal  genitalia,  476 
of  mucous  surfaces,  476 
of  serous  membranes,  476 
and  acute  endometritis,  478 
and  acute  salpingitis,  478 
and  cystitis,  508 
and  peritonitis  in  infants,  478 
and  urethritis,  507 
clinical  course  of,  476 
chronic,  477 

complement  fixation  test  in, 

479 
discharge  in,  477 
erosion  of  cervix  in,  477 
gonococcus  in,  477 
opthalmia  from,  478 
puerperal  infection  from  478 

in  infants,  476 

methods  of  infection  in,  476 

permanence  of,  476 

recurrent  salpingitis  in,  478 

treatment  of,  479 
cautery  in,  480 
dry,  479 
iodin  in,  479 
medical,  479 
silver  solution  in,  479 
surgical,  479 
Gonorrheal  salpingitis,  479 
Greater  vestibular  glands,  108 


668 


INDEX 


Greater  vestibular  glands,    abscess 
of,  109 

excision  of,  109 

incision  of,  109 

infection  of,  108 
Gynaecologic  examination,  57 

pain,  56 

surgery,  561 

H 

Hand  disinfection,  566 

Harrington  solution  in  preparation 

of  operative  field,  565 
Hematocele,  pelvic,  394 
Hematoma,  pelvic,  394 
Hemorrhage  from  vulva,  117 
in  cancer  of  cervix,  188 
in  cervical  polypi,  179 
post-operative,  613 
from  cervix,  616 
from  perineum,  616 
intra-abdominal,  613 
symptoms  of,  614 
treatment  of,  614 

saline  solution  in,  615 
secondary  operation  in,  615 
serum  injection  in,  615 
varieties  of,  613 
Hemorrhoids,  515 
external,  516 

prophylaxis  of,  516 
treatment  of,  516 
internal,  capillary,  525 
venous  variety,  517 
diagnosis  of,  518 
from  carcinoma,  518 
hemorrhage  from,  517 
inflammation  of,  517 
treatment  of,  518 
anaesthesia  in,  519 
clamp  and  cautery,  520 
injection,  519 
ligature,  521 
palliative,  518 
post-operative       hemor- 
rhage, 525 


Hemmorrhoids,  internal,  treatment, 

523 
Hemostasis  in  gynaecologic  surgery, 
586 

blood  transfusion  for,  587 

by  crushing,  586 

by  drainage,  587 

by  heat  and  pressure,  587 

by  ligature,  587 

serum  injection  for,  587 
Hermaphroditism,  459 

male  pseudo-,  459 
Hernia  into  labia,  no 
Hirst's  operation  for  vaginismus,  116 
History,  family,  54 

personal,  55 
Hydrocele,  no 
Hydronephrosis  from  cancer  of  the 

cervix,  187 
Hydrosalpinx,  355 
Hydrotherapy  in  constipation,  483 

in  gynaecology,  492 
Hymen,  hemorrhage  from,  117 

imperforate,  462 
operation  for,  467 
infection  after,  468 
laparotomy  for,  468 

laceration  of,  117 
Hyperaemia,  Bier's,  503 
Hyperaesthesia    in    acute    appendi- 
citis, 531 
Hyperin volution  of  uterus,  226 

and  perforation,  226 
Hypertrophy  of  cervix,  183 

amputation  for,  183 

and  laceration,  183 

congenital,  183 
Hysterectomy  and  cystitis,  508 

in  dysmenorrhea,  483 

supravaginal,  314 

total,  331 

vaginal,  288 


Incisions,  closing  of,  591 
for  appendectomy,  544 


INDEX 


669 


Incisions,    in   gynaecologic   surgery, 

583 

Pfannenstiel's,  583 
Infection,  peritoneal,  618 

from  endogenous  sources,  618 
from  intestinal  injury,  618 
general,  619 
local,  619 
treatment  of,  619 
cathartics  in,  619 
drainage  in,  619 
morphine  in,  619 
starvation  in,  619 
with  abscess  formation,  619 
post-operative,  616 

after  plastic  operations,  616 
of  abdominal  wall,  617 
from  appendectomy,  617 
haematomata  in,  617 
treatment  of,  617 
drainage  in,  617 
iodin  in,  617 
saline  dressings  in,  618 
vaccines  in,  618 
Insomnia,  490 
baths  in,  490 
bromides  in,  490 
hypnotics  in,  491 
Instruments  for  examination,  71 
in  gynsecologic  surgery,  581 
Internal  hemorrhoids,  517 
Interstitial  endometritis,  223 
Intestinal  obstruction  from  foreign 
bodies,  643 
post-operative,  620 
etiology  of,  620 
adhesions  in,  620 
bands  in,  620 
intestinal  paresis  in,  620 
symptoms  of,  621 

constipation  in,  620 

pain  in,  620 

pulse  and  temperature  in, 

620 
tympany  in,  620 
vomiting  in,  620 


Intestinal  obstruction,  treatment  of, 
621 
catharatics  in,  621 
enemas  in,  621 
lavage  in,  62 1 
operative,  622 

with  gangrene,  622 
incision  for,  622 
intestinal    resection    in, 

624 
locating   obstruction   in, 
622 
paresis  in  peritonitis,  442 
resection  for  fecal  fistula,  636 
drainage  after,  639 
lateral  anastomosis  in,  636 
sutures  in,  637 
technique  of,  637 
for  obstruction,  624 
enterostomy  in,  629 
fecal  fisttila  in,  630 
jejunostomy  in,  630 
Murphy  button  in,  628 
sutures  in,  625 
technique  of,  624 
Inversion  of  the  uterus,  274 
acute,  274 

mechanism  of,  274 
chronic,  275 

and  myoma,  277 
examination  in,  275 
hysterectomy  for,  277 
incision  of  cervix  for,  277 
replacement  of,  277 
symptoms  of,  275 
Iodin   in   preparation   of   operative 

field,  566 
Iron  in  chlorosis,  480 


K 


Knots,  surgical,  590 
Kraurosis  vulvae,  103 

and  premature  menopause,  103 


670 


INDEX 


Labor,  51 

cause  of  onset  of,  51 
Laceration  of  cervix,  181 

amputation  for,  201 

and  backache,  181 

and  carcinoma,  181 

and  hypertrophy,  181 

and  leucorrhea,  181 

diagnosis  of,  182 

immediate  repair  of,  193 
anaesthesia  in,  193 
indications  for,  193 
sutures  in,  194 

reflex  symptoms  from,  182 

secondary  repair  of,  194 
after-care  in,  197 
denudation  for,  194 
indications  for,  194 
secondary   hemorrhage  in, 

197 
sutures  in,  194 

treatment  of,  182 
by  amputation,  198 
by  immediate  suture,  182, 

193 

by  secondary  repair,  194 
of  perineum,  120 
LeFort  operation,  259 
Leucocytosis  in  acute  appendicitis, 

531 

in  chronic  appendicitis,  542 

in  diagnosis,  85 

in  pelvic  peritonitis,  444 

in  pneumonia,  534 
Leucorrhea,  59 

and  endometritis,  61 

microscopic  character  of,  60 

odor  of,  59 

origin  of,  60 

purulent,  60 

reaction  of,  59 
Levator  ani  muscle,  1 1 
Ligaments,  broad,  39 

recto-uterine,  23 


Ligaments,  round,  39 

sacro-uterine,  23 

uterine,  39 

vesical,  36 
Ligatures  and  sutures,  tying  of,  590 
Ligature  materials,  587 

operation  for  hemorrhoids,  521 
Lipomata  of  vulva,  no 
Local  therapy  in  gynaecology,  496 

M 

Maculae  cerulae,  116 

Magnesium  sulphate  in  bacteremia, 

495 
Malignant  disease  of  uterine  body, 

241 
Medication,  pre-operative,  563 
Menopause,  46 

Menorrhagia  and  metrorrhagia,  483 
the  treatment  of,  483 

astringent  douches  in,  484 
gauze  pack  in,  484 
internal  medication  in,  484 
serum  injection  in,  484 
Menorrhagia  as  a  symptom,  66 

etiology  of,  66 
"Menstrual   abortion"    and    steril- 
ity, 473 
Menstrual  blood,  45,  49 

origin  of,  48 
Menstrual  disorders,  61 

classification  of,  61 
treatment  of,  480 
amenorrhea,  480 
dysmenorrhea,  481 
menorrhagia    and    metror- 
rhagia, 483 
Menstruation,  44 

after  unilateral  castration,  47 

age  of  onset,  45 

and  corpus  luteum,  47 

and  internal  secretions,  47 

and  lactation,  45 

and  ovulation,  47 

cause  of,  46 


INDEX 


671 


Menstruation,  cessation  of,  46 

definition  of,  44 

duration  of,  45 

histology  of,  47 

hormone  of,  47 

in  the  new-born,  45 

irregular  in  extra-uterine  preg- 
nancy, 388,  389 

precocious,  45 

suppression  of,  63 
Metritis,  chronic,  226 

physical  findings  in,  227 

symptoms  of,  226 

treatment  of,  227 
Metrorrhagia  as  a  symptom,  67 

etiology  of,  67 
Microscopic  examination,  84 
Mixed  hemorrhoids,  517 
Morphine  in  carcinoma  of  cervix,  192 
"Morris"  appendix,  539 
Mucous  colitis  and  appendicitis,  542 

polypi,  225 
Murphy,  hysterectomy,  327 
Myomata  of  the  uterus,  227 
Myomectomy,  309 

abdominal,  312 

vaginal,  309 


N 


Narcotics  in  dysmenorrhea,  482 
Nephroptosis,  557 
Neuroses,  functional,  488 


O 


Obesity  and  amenorrhea,  481 
Ochsner's  treatment  of  appendicitis, 

538 
Oophorectomy  in  dysmenorrhae,  483 
Oophoritis,  acute,  406 

acute  peritonitis  from,  407 

abscess  from,  406 

clinical  course  and  prognosis 
of,  406 

etiology  of,  406 

late  results  of,  412 


Oophoristi,    acute,    pelvic    abscess 
from,  407 J 

symptoms  and  diagnosis  of, 

407 
after  labor,  406 
differential  diagnosis,  409 
from  appendicitis,  409 
from  ectopic  pregnancy, 

410 
from  specific  salpingitis, 
409 
history  in,  407 
leucocyte  count  in,  407 
menstruation  in,  408 
nausea  and  vomiting  in,  407 
pain  in,  407 

physical  findings  in,  407 
treatment  of,  410 
palliative,  411 
cathartics  in,  411 
narcotics  in,  411 
vaginal   applications   in, 
411 
surgical,  411 

laparotomy  in,  412 
vaginal  incision  in,  41 1 
chronic,  412 
Ovarian  artery,  32 

fossa,  32 
Ovarian  tumors,  415 

accidents  to,  421 
inflammation  of,  422 
suppuration  of,  422 
torsion  of  pedicle  of,  424 
clinical  course  and  prognosis 

of,  421 
differential  diagnosis  of,  425 
from  ascites,  428 
from  fibro-myomata,  427 
from  hydrosalpinx,  426 
from  pregnancy,  426 
from  tuberculous  peritoni- 
tis, 428 
etiology  of,  415 
pathology  of,  415 
parenchymatogenous,  415 


672 


INDEX 


Ovarian    tumors,    pathology    of 
stromatogenous,  415 
symptoms  and  diagnosis  of, 
424 
ascites  in,  425 
physical  findings  in,  425 
treatment  of,  428 
by  excision,  429 
by  resection,  428 
Ovaries,  congenital  anomalies  of,  467 
accessory,  467 
and  internal  secretions,  467 
Ovariotomy,  429 
incision  in,  430 

management  of  pedicle  in,  430 
peritoneal  soiling  in,  434 
intestinal  resection  in,  437 
injury  to  viscera  in,  434 
rupture  of  cyst  in,  434 
separation  of  adhesions  in,  434 
tapping  in,  436 
with  adherent  tumor,  434 
Ovary,  32 

anatomy  of,  32 
blood  supply  of,  33 
diseases  of,  406 

carcinomata  of,  415 
cyst-adenomata  of,  418 
dermoids  of,  416 
fibromata  of,  415 
inflammation  of,  406 
papillomata  of,  417 
retention  cyst  of,  415 
sarcomata  of,  415 
tumors  of,  415 
pedicle  of,  420 
follicles  of,  33 
ligaments  of,  32 
lymphatics  of,  33 
prolapse  of,  413 
adherent,  413 
inflamed,  413 
physical  findings  in,  414 
symptoms  of,  413 
treatment  of,  414' 
pessaries  in,  414 


Ovary,   prolapse   of,   surgical, 
treatment  of,  414 
with   displacement   of 
uterus,  414 
relations  of,  32 
resection  of,  428 
Ovulation,  49 

and  menstruation,  47,  49 
definition  of,  49 
Oxyuris  vermicularis,  117 


Pain,  gynecologic,  56 

in  dysmenorrhea,  65 

location  of,  56 

reflex,  58 

types  of,  59 
Palpation,  bi-manual  vaginal,  82 

in  diagnosis,  78 

vaginal,  81 
Pan-hysterectomy,  331 

drainage  after,  334 

indications  for,  331 

mortality  of,  331 

technique  of,  331 

vaginal  incision  preceding,  331 

for  carcinoma,  336 

cauterization  preceding,  336 
combined  operation  in,  348 
drainage  after,  345 
principles  of,  336 
vaginal  clamps  in,  343 
Wertheim's  method  of,  336 
Papilloma  of  ovary,  pathology  of, 

417 
malignancy  of,  421 
Parametrium,  41 
Para-urethral    ducts,    inflammation 

of,  508 
Parovarian  cystectomy,  437 
blunt  dissection  in,  437 
hysterectomy  in,  438 
peritoneal  incision  in,  437 
preliminary    haemostasis    in, 

438 
the  ureter  and,  437 


INDEX 


673 


Parovarian  cysts,  415 

pathology  of,  420 
removal  of,  437 
Pediculosis  pubis,  116 
Pelvic  abscess,  445 
basin,  20 
brim,  20 

structures  at,  20 
cellulitis,  acute,  449 

chronic,  451 
compartments,  23 
contents,  20,  23 

relations  of,  20-23 
diaphragm,  11 
fascia,  41 
floor,  II 

muscles  of,  1 1 
nerves  of,  14 
peritonitis,  acute,  440 
chronic,  448 
Percy's  cauterization,  212 
Percussion  in  diagnosis,  75 
Perforation  of  uterus,  278 
diagnosis  of,  279 
during  myomectomy,  312 
gauze  packing  in,  279 
laparotomy  for,  279 
post-partum,  279 
results  of,  278 
Perineal  body,  11,  120 
laceration,  120 

classification  of,  120 
complete,  121 

immediate  repair  of,  126 
secondary  repair  of,  152 
simple  operation  for,  153 
split  flap  operation  for,  153 
denudation  in,  153 
sutures  in,  155 
incomplete,  immediate  repair 
of,  126 
anaesthesia  in,  129 
asepsis  in,  128 
complicated,  128 
small  median,  127 
secondary  repair  of,  132 
43 


Perineal  laceration,  secondary  repair 
of,  perineorrhaphy  in,  1 38 
methods,  139 
Emmett's,  142 
denudation  in,  142 
sutures  in,  144 
Hegar's,  140 

denudation  in,  141 
sutures  in,  141 
split  flap  operation,  147 
denudation  in,  150 
sutures  in,  151 
suture  material  in,  131 
secondary  results  of,  122 
region,  5 

anatomy  of,  5 
blood  supply  of,  5 
fascia  of ,  8 
lymphatics  of,  5 
muscles  of,  6 
nerves  of,  6 
Perineorrhaphy,  secondary,  132,  138, 
152  , 
after-care  of,  160 
cathartics  in,  160 
catheterization  in,  160 
diet  in,  160 
douches  in,  160 
enemas  in,  160 
asepsis  in,  158 
Perineum,  central  point  of,  6 
Peritoneum,  pelvic,  20 

relations  of,  20 
Peritonitis,  acute,  440 

classification  of,  440 
pelvic,  440 

and  intestinal  paresis,  442 
clinical  etiology,  441 

from  chemical  irritation, 

441 
from  infection,  441 
from  trauma,  441 
gross  pathology  of,  442 
prognosis  of,  446 

facial  expression  in,  447 
gonorrheal,  446 


674 


INDEX 


Peritonitis,  acute  pelvic,  prognosis 
of  septic,  446 
symptoms  and  diagnosis  of, 

443 
abscess  formation  in,  445 
constipation  in,  443 
differential  diagnosis  of, 

from  extra-uterine, 
pregnancy,  446 

from     intestinal     ob- 
struction, 445 
hyperaesthesia  in,  444 
leucocyte  count  in,  444 
pain  in,  443 
pelvic  mass  in,  444 
physical  findings  in,  443 
rectal  tenesmus  in,  445 
rigidity  in,  444 
temperature    and    pulse 

in,  443 
vomiting  in,  443 
treatment  of,  447 
appendicular,  447 
diffuse,  448 
general,  448 
gonorrheal,  447 
perforative,  447 
vaginal  section  in,   447, 
448 
chronic,  448 

sclerosing,  448 
from  salpingitis,  355 
post-operative,  618 
Pessaries  for  diagnosis,  271 
for  prolapse,  256 
for  retrodisplacements,  269 
Phlebitis,  post-operative,  649 
etiology  of,  649 

varices  in,  649 
symptoms  of,  649 
treatment  of,  649 

magnesium  sulphate  in,  650 
Physiology  of  reproductive  organs,  44 
Pin  worms,  117 

Pneumonia,  post-operative,  646 
Polypi  of  cervix,  178 


Polypi,  uterine,  225 
Positions  for  examination,  69 

erect,  71 

knee-chest,  71 

Sim's,  70 
Post-operative  adhesions,  650 

bronchitis,  646 

dilatation  of  stomach,  643 

hemorrhage,  613 

infection,  616 

intestinal  obstruction,  620 

nausea,  602 

peritonitis,  618 

phlebitis,  649 

pneumonia,  646 

psychoses,  651 

pulmonary  embolism,  648 

pulse,  602 

respiration,  603 

shock,  611 

suppression  of  urine,  644 

temperature,  602 
Pregnancy  after  ventro-suspension, 

307 

and  gynaecologic  disease,  52 

and  labor,  51 

duration  of,  51 

extra-uterine,  381 
Pre-operative  treatment,  562 

catharsis  in,  562 

diet  in,  562 

medication  in,  563 
Procidentia,  252 
Prolapsus  uteri,  252 

bladder  irritability  in,  255 

causes  of,  252 

congenital,  254 

cystocele  and,  252 

degrees  of,  252 

diagnosis  of,  255 

pain  in,  254 

retroversion  and,  254 

strangulation  in,  255 

treatment  of,  256 

LeFort  operation,  259 
mechanical,  256 


INDEX 


675 


Prolapsus  uteri,  operative  treatment 
of,  257 

iilceration  of  the  cervix  in,  255 
Pruritis  vulvae,  loi 

idiopathic,  102 

and  diabetes,  102 

iodine  in,  102 

nerve  sedatives  in,  102 

operation  for,  103 

salicylic  acid  in,  102 

X-ray  and  radium  in,  103 
Pseudo-hermaphroditism,  459 
Psychoses,    post-operative,    predis- 
posing causes,  651 

anaesthesia,  652 

infection,  653 

premature  menopause,  652 
Ptosis,  visceral,  555 
Pulmonary  embolism,  648 

symptoms  of,  648 

treatment  of,  649 
Pulse,  post-operative,  602 
Purgatives  in  appendicitis,  538 
Puriilent  endometritis,  220 
Pyelitis,  510 
Pyosalpinx,  355 

rupture  of,  357 
Pyuria,  persistent,  511 

R 

Radiotherapy  in  gynaecology,  503 
Radium  in  carcinoma  of  cervix,  191 
of  vagina,  166 

in  gynaecology,  503 
Rectocele,  125 

etiology  of,  125 
Recto-uterine  excavation,  24 

ligaments,  23 
Recto-vaginal  fistula,  167 

cautery  in,  172 

operation  for,  172 
Rectum,  18 

anatomy  of,  18 

anal  part  of,  19 

blood  supply  of,  19 

columns  of,  19 


Rectum,  lymphatics  of,  20 
nerves  of,  20 
valves  of,  19 
white  line  of,  19 
Resection,  intestinal,  624,  636 
of  ovary,  sutures  in,  429 
technique  of,  428 
Respiratory   infections,    post-opera- 
tive, 646 
etiology  of,  646 
aspiration  in,  647 
ether  anaesthesia  in,  646 
exposure  in,  647 
pneumococci  in,  647 
pulmonary  infarcts  in,  647 
prognosis  of,  647 
symptoms  of,  647 
treatment  of,  647 
Rest  in  gynaecology,  488 
Retention  cysts  of  ovary,  416 
Retroflexion  and  retroversion,  263 
acute,  265 
adhesions  in,  266 
causes  of,  263 
congenital,  264 
diagnosis  of,  266 
knee  chest  posture  for  replace- 
ment of,  268 
mechanical  treatment  of,  269 
operative  treatment  of,  272 
indications  for,  272 
methods  of,  272 
pain  in,  266 

postural  treatment  of,  269 
replacement  of,  forcible,  267 
replacement  with  sound,  269 
symptomless,  265 
Rigidity  in  actue  appendicitis,  531 
Round  ligaments,  39 
anatomy  of,  39 
inguinal  shortening  of,  297 
intra-abdominal  shortening  of, 
300 
Rupture  of  uterus,  280 
drainage  after,  281 
during  dilatation,  280 


676 


INDEX 


Rupture  of  uterus,   gauze  packing 
in,  280 
hysterectomy  for,  281 
into  broad  ligaments,  280 
into  peritoneal  cavity,  280 
suture  in,  281 


Salpingitis,  acute,  353 

differential  diagnosis  of,  360 

exudate  in,  359 

fever  in,  358 

gonorrheal,  354 

hyperacute,  358 

hyper aesthesia  in,  358 

leucocyte  count  in,  361 

leucorrhea  in,  360 

peritonitis  from  355 

prognosis  of,  362 

recurrence  of,  357 

regidity  in,  358 

septic,  353 

sub-acute,  359 

treatment  of,  363 
medical,  363 
surgical,  364 
and    extra-uterine    pregnancy, 

382 
and  gonorrhea,  473 
and  menstruation,  358 
and  sterility,  474 
chronic,  355 

definition  of,  360 

origin  of,  355 

treatment  of,  365 
tuberculous,  365 
and     tuberculous     peritonitis, 

365 
Salpingectomy    and    oophorectomy. 

370 

clamp  and  ligature  method,  372 
drainage  after,  375 
haemostasis  in,  374 
ligature  method,  371 
special  points  in  technique  of, 
377 


Salpingectomy   and   oophorectomy, 
sutures  in,  373 
visceral  injury  during,  369 
Sarcoma  and  fibromata  of  the  uterus, 

234 

of  ovary,  415 
of  uterine  body,  243 
Coley's  toxins  in,  244 
microscope  in  diagnosis,  244 
radiotherapy  in,  244 
of  vulva.  III 
Schroeder's    amputation    of    cervix, 

198 
Segregator,  Harris',  92 
Sexual  orgasm  and  sterility,  473 
Shock   in   extra-uterine   pregnancy, 
388,  392 
post-operative,  611 
differentiation  of,  611 
etiology  of,  611 
prevention  of,  612 
symptoms  of,  611 
treatment  of,  612 
Sitz  bath,  502 
Sponges  overlooked,  641 
Stem  pessary  in  amenorrhea,  481 

in  sterility,  475 

Stenosis  of  the  cervix,  184 

cicatricial,  184 

congenital,  184 

Sterility,  etiology  of,  471 

cervical  atresia  in,  472 
defective  ovulation  in,  473 
defects  of  vulva  and  hymen 

in,  471 
destruction    of    spermatozoa 

in,  472 
hyperacidity  of  secretions  in, 

472 
mechanical     interference     in 

tubes,  472 
menstrual  abortion  in,  473 
syphiHs  in,  474 
uterine  disease  in,  473 
displacements  in,  472 
fibroids  in,  473 


INDEX 


677 


Sterility  in  diagnosis  of  extra-uterine 
pregnancy,  389 
treatment  of,  474 

alkaline  douches  in,  475 
anti-syphilitic,  475 
curettage  in,  475 
intra-uterine  stem  pessary  in, 

475 
operations  on  tubes  in,  474 
Sterilization,  565 
of  hands,. 566 
of  instruments,  569 
of  operative  field,  564 
of  surgical  materials,  568 
of  suture  material,  570 
Stitch  abscess,  617 
Stomach,  acute  dilatation  of,  643 
Strangulation  of  uterus,  255 
Sub-involution  of  uterus,  226 
"  Sub-total "  hysterectomy,  314 
Suggestion  in  gynaecology,  492 
Suppositories,  vaginal,  496 
Supra-vaginal  hysterectomy,  314 
adhesions  in,  315,  322 
for  cervical  fibroids,  328  . 
Murphy's  method,  227 
for    intra-ligamentary    tumors, 

323 
side  to  side  operation,  324 
for  large  cervical  fibroids,  328 

incision  of  uterus  for,  330 
landmarks  for,  315 
separation  of  peritoneum  in,  316 
severing  of  cervix  in,  319 
special  points  in  technique  of, 

322 
sutures  and  ligatures  in,  320 
Trendelenburg  position  in,  322 
uterine  arteries  and  ureters  in, 
318 
Suture  material,  587 
Sutures,  layer,  592 
tension  on,  593 
through  and  through,  591 
Syphilis  and  condylomata,  106 
and  sterility,  474 


Syphilis  of  vulva,  104 


Tampons,  vaginal,  498 
Technique,  dressing,  599 
Temperature,  post-operative,  602 
Thrombotic  pile,  516 
Trachelorrhaphy,  194 
Trendelenburg    operation    for    pul- 
monary embolism,  649 
Tubal  pregnancy,  381 
Tuberculosis  and  cystitis,  513 
Tuberculous  appendicitis,  540 

salpingitis,  365 
Tumors  of  the  cervix,  184 

of  the  ovary,  415 

of  the  vagina,  166 
Tympany  in  appendicitis,  532 
Typhoid  fever  and  suppuration  of 
ovarian  cysts,  422 


U 


Ulcer,  phagadenic,  106 
"Ulceration"  of  the  cervix,  176 
Ulceration    of    cervix   in   prolapsus 

uteri,  255 
Ureter,  catheterization  in  diagnosis, 

92 
Urethral  caruncle,  1 1 1 
Ureters,  38 

accidental  injury  to,  645 
ligation  of,  645 
bilateral,  645 
nephrotomy  in,  646 
treatment  of,  645 
unilateral,  645 
constrictions  of,  39 
course  of,  38 
relations  of,  38 
Urethra,  18 

anatomy  of,  18 
Urethritis,  507 

gonorrhea  and,  507 


678 


INDEX 


Urethritis,  symptoms  of,  507 
treatment  of,  507 
general,  507 
local,  507 
Urine  in  acute  cystitis,  509 
in  diagnosis,  92 

segregation  of,  92 
suppression,  post-operative,  644, 
from  acute  nephritis,  644 
nephrotomy  in,  644 
treatment  of,  644 
venesection  in,  644 
from  ligation  of  ureters,  645 
Uterine  artery,  31 

body,  malignant  disease  of,  241 

sarcoma  of,  243 
bruit,  77 
fibroid,  227 
ligaments,  39 
anatomy  of,  39 
inguinal  shortening  of,  297 
intra-abdominal  shortening  of 
300 
Baldy-Webster    operation, 

302 
Gilliam  operation,  301 
polypi,  225 

hemorrhage  from  226 
histological  structure  of,  225 
tubes,  33 

anatomy  of,  33 
blood  supply  of,  35 
coats  of,  34 

congenital  anomalies  of,  466 
lumen  of,  34 
lymphatics  of,  35 
mesentery  of,  34 
nerves  of,  35 
Uterus,  26 

anatomy  of,  26 
anteflexion  of,  262 
anteversion  of,  260 
ascent  of,  251 
blood  supply  of,  31 
cavity  of,  29 
cervix  of,  28 


Uterus,  coats  of,  30 

congenital  anomalies  of,  464 

double,  464 

pregnancy  in,  466 

septate,  464 

unicornate,  466 
corpus  of,  26 
curettage  of,  283 
displacements  of,  248 

classification  of,  250 
fibro-myomata  of,  227 
fixation  of,  251 
glands  of,  31 
hyperinvolution  of,  226 
inversion  of,  274 
mal  locations  of,  250 
mal  positions  of,  250 
margins  of,  27 
nerves  of,  32 
normal  position  of,  248 
operations  on,  283 
perforation  of,  278 
prolapse  of,  252 

retroversion  and  retroflexion  of, 
263 
'  rupture  of,  280 
strangulation  of,  255 
sub-involution  of,  226 
surfaces  of,  26 
vaginal  fixation  of,  285 
ventro-fixation  of,  273,  307 
ventro-suspension  of,  273,  306 


V 


Vaccines  in  cystitis,  514 

in  gynaecology,  494 
Vagina,  14 

acute  inflammation  of,  163 

anatomy  of,  14 

blood  supply  of,  17 

canal  of,  15 

chronic  inflammation  of,  163 

coats  of,  16 

columns  of,  16 

congenital  anomalies  of,  463 


INDEX 


679 


Vagina,  congenital  absence  of,  464 
operations  for,  intestinal  trans- 
plantation in,  469 
double,  464 
stenosis  of,  463 
cysts  of,  166 
fistula  of,  167 
fornices  of,  16 
injuries  of,  166 
nerves  of,  18 
relations  of,  16 
rugae  of,  16 
tumors  of,  166 
Vaginal  douches,  501 

antiseptics  in,  501 

astringents  in,  501 

carbolic  in,  501 

mercurials  in,  501 
fixation,  285 

contra-indications  to,  286 

incisions  for,  286 

indications  for,  285 

sutures  in,  287 
hysterectomy,  288 

after-care  of,  296 

by  clamp  method,  291 

by  ligature  method,  294 

dangers  of,  289 

drainage  after,  295 

for  carcinoma  of  cervix,  190 
of  uterus,  288 

for    inflammatory    disease, 
288 

for  prolapsus  uteri,  258,  288 

incisions  for,  289 

modifications  of,  294 

special  points  in  technique  of, 
296 
myomectomy,  309 

anaesthesia  in,  312 

dilatation  of  cervix  in,  311 

incision  of  capsule  in,  309 
of  cervix  in,  312 

morcellation  in,  310 

packing  after,  312 

perforation  of  uterus  in,  312 


Vaginal  palpation,  81 
bimanual,  82 
section,  452 

and  drainage,  457 
catheterization  after,  457 
in  acute  cellulitis,  450 
in  peritonitis,  447,  448 
in  diagnosis  of  acute  oophori- 
tis, 411 
of  extra-uterine  pregnancy, 

391 

indications  for,  452 

in  treatment  of  extra-uterine 

pregnancy,  403 
posterior,  advantages  of,  452 
technique  of,  452 
Vaginismus,  112 

and  prolapsed  ovary,  114 
Hirst's  operation  for,  116 
Vaginitis,  acute,  163 
etiology  of,  163 
chemical  irritation  in,  163 
gonorrhea  in,  163 
infection  in,  163 
traumatism  in,  163 
local  signs  and  symptoms  of, 

164 
treatment  of,  164 
carbolic  acid  in,  164 
diphtheria  antitoxin  in,  164 
douches  in,  164,  165 
drainage  in,  164 
in  infants,  166 
saline  solutions  in,  165 
in  vesico-vaginal  fistula,  168 
senile,  166 

trophic  disturbances  in,  164 
Varices  of  vulva,  no 
Ventro-fixation      in      retrodisplace- 
ments,  273 
Crile's  operation  of,  308 
sutures  in,  308 
Ventro-suspension  in  retrodisplace- 
ments,  273 
contra-indications  to,  307 
immediate  results  of,  307 


68o 


INDEX 


Ventro-suspension  in  retrodisplace-s 
ments,    remote  results  of,\ 
307 
sutures  in,  307 
Vesico-uterine  excavation,  22 
Vesico-vaginal  fistula,  167 
and  cystitis,  512 
cautery  in,  169 
operations  for,  169,  170 
after-care  of,  170 
denudation  in,  169 
sutures  in,  169 
sloughing  as  cause  of,  167 
supra-pubic  operation  for,  171 
Visceral  ptosis,  555 
backache  in,  556 
bandages  in,  557 
operations  for,  557 
with  adhesions,  556 
Vulva,  2 

abscess  of,  98 
anatomy  of,  3 
clitoris,  4 
fourchette,  3 
hymen,  5 
labia  majora,  3 

minora,  3 
larger  vestibular  glands,  4 
mons  pubis,  3 
vaginal  vestibule,  4 
vestibular  bulbs,  4 
chancre  of,  103 
chancroid  of,  105 
condylomata  of,  106 
congenital  anomalies  of,  459 
embryonic  cloaca,  462 
hermaphroditism,  459 


Vulva,  congenital  anomalies  of  im- 
perforate hymen,  462 

diseases  of,  97 

eczema  of,  99 

erysipelas  of,  98 

gonorrohea  of,  98 

haematoma  of,  117 

hemorrhage  from  117 

herpes  of,  99 

injuries  of,  117 

kraurosis  of,  103 

parasites  of,  116 

pruritis  of,  loi 

stenosis  of,  loi 

tumors  of,  no 
excision  of ,  1 1 1 
radium  in,  in 
Vulvitis,  97 

chemical  irritation  in,  97 

discharge  in,  98 

follicular,  100 

gonorrheal,  98 

infection  in,  97 

traumatism  in,  97 
Vulvo-vaginitis  in  infants,  476 

W 

Wertheim's  operation  for  carcinoma, 

336 

Wounds,  suture  of,  591 
methods  of,  591 

X 

X-ray  for  carcinoma  of  cervix,  191 
of  vagina,  166 
in  gynaecology,  503 


\. 


% 


^      i      lui  1  jc^i^iyt    »S^i. 


